Personality traits as mediators of the relationship between childhood trauma and depression severity in bipolar disorder: A structural equation model

BACKGROUND

Childhood trauma is negatively associated with depression severity in bipolar disorder; however, the underlying mechanisms remain unclear. We investigated whether personality traits (neuroticism, extraversion, openness, agreeableness, conscientiousness) mediate the relationship between childhood trauma and the severity of bipolar depression.

METHODS

Data from 209 individuals with bipolar disorder recruited for the Prechter Longitudinal Study of Bipolar Disorder were analysed. Using structural equation modelling, we examined the direct and indirect associations between childhood trauma (Childhood Trauma Questionnaire) and depression severity (Hamilton Depression Rating Scale) - with the personality traits (NEO Personality Inventory-Revised) as mediators.

RESULTS

The direct effect of childhood trauma on depression severity (standardised β = 0.32, 95% bootstrap confidence interval [CI] = 0.20-0.45, p < 0.001) and the indirect effect via neuroticism (standardised β = 0.03, 95% bootstrap CI [0.002, 0.07], p = 0.039) were significant; supporting a partial mediation model. The indirect effect accounted for 9% of the total effect of childhood trauma on depression severity (standardised β = 0.09, 95% bootstrap CI [0.002, 0.19], p = 0.046). The final model had a good fit with the data (comparative fit index = 0.96; root mean square error of approximation = 0.05, 90% CI = [0.02, 0.07]).

CONCLUSION

Personality traits may be relevant psychological mediators that link childhood trauma to a more severe clinical presentation of bipolar depression. Consequently, a person's personality structure may be a crucial operative factor to incorporate in therapeutic plans when treating individuals with bipolar disorder who report a history of childhood trauma.

Feasibility of the community-based Stay at Work Intervention (SAWI) for stroke survivors

BACKGROUND: Rates of stroke in people of working age are increasing. Returning to work (RTW) after stroke is a key rehabilitation aspiration for younger stroke survivors. A pilot community-based Stay at Work Initiative (SAWI) was developed and delivered from March 2017 to December 2019. SAWI used a co-ordination based approach, covering rehabilitation and vocational recovery to support RTW in younger stroke survivors. OBJECTIVE: The aim of the study was to conduct a feasibility evaluation of SAWI. METHODS: A mixed methods approach was taken considering quantitative and qualitative data. Quantitative data included employment, mood, anxiety and fatigue outcomes at time of engagement with the service and at 6-months post-stroke. Qualitative data was collected on a sub-sample of SAWI clients who volunteered to participate in a semi-structured interview. RESULTS: Overall, there were 93 referrals to SAWI, with 42 clients completing an initial service meeting. Average working hours pre-stroke were high (mean 46.9, SD 22.0, range 5–100 hours/week). By 6 months post stroke, 71% (n = 29 of 41) of SAWI clients were working. For those with 6-month questionnaire information (n = 19), there was a significant reduction in cognitive fatigue, overall fatigue levels, and perceived impact of stroke on employment (medium effect sizes of r = 0.36, 0.34 and 0.40 respectively). No significant difference was seen on measures of mood or anxiety from pre- to post-intervention. Qualitative interviews with six SAWI participants highlighted the importance of personalised support that addresses individual needs during the RTW journey. CONCLUSIONS: A significant number of eligible participants referred to SAWI can engage with the service. RTW is able to be assessed as are potential predictor variables. Seventy one percent of participants had RTW at 6 months post-stroke. Mood, self-efficacy, adjustment, and fatigue likely impact RTW. Qualitative interviews identified that SAWI’s personalised support, tailored to individual need, was valued.

Attachment insecurity partially mediates the relationship between childhood trauma and depression severity in bipolar disorder

BACKGROUND

Childhood trauma is associated with greater depression severity among individuals with bipolar disorder. However, the mechanisms that explain the link between childhood trauma and depression severity in bipolar disorder remain poorly understood. The mediational role of attachment insecurity in childhood and adulthood was assessed in the current study.

METHODS

Participants with bipolar disorder (N = 143) completed measures of childhood trauma (Childhood Trauma Questionnaire), attachment insecurity (Experiences in Close Relationships Scale) and depression severity (Hamilton Depression Rating Scale) as part of the Prechter Longitudinal Study of Bipolar Disorder. A sequential mediation model was tested using path analysis: the direct and indirect effects of childhood trauma on depression severity with attachment insecurity (attachment anxiety and avoidance) in childhood (mother and father) and adulthood (partner) as mediators were estimated.

RESULTS

The final path model demonstrated an excellent fit to the data (comparative fit index = 0.996; root mean square error of approximation = 0.021 [90% confidence interval = 0.000-0.073]). Supporting the hypothesised sequential mediation model, maternal attachment anxiety in childhood and romantic attachment avoidance in adulthood partially mediated the relationship between childhood trauma and depression severity; this effect accounted for 12% of the total effect of childhood trauma on depression severity.

CONCLUSION

Attachment insecurity in childhood and adulthood form part of the complex mechanism informing why people with bipolar disorder who have a history of childhood trauma experience greater depression severity. Addressing attachment insecurity represents a valuable psychotherapeutic treatment target for bipolar disorder.

Childhood trauma and treatment outcomes during mood-stabilising treatment with lithium or quetiapine among outpatients with bipolar disorder

BACKGROUND

Childhood trauma affects the course of mood disorders. Researchers are now considering childhood trauma as an influential factor in the treatment of mood disorders. However, the role of childhood trauma in the treatment of bipolar disorder remains understudied.

METHODS

The effect of childhood trauma on treatment outcomes was evaluated among participants randomised to treatment with lithium or quetiapine in the Clinical and Health Outcomes Initiatives in Comparative Effectiveness for Bipolar Disorder (Bipolar CHOICE) study by clinician assessment. Mixed effects linear regression models were used to analyse rates of improvement in symptom severity (assessed with the Bipolar Inventory of Symptoms Scale and the Clinical Global Impression Scale for Bipolar Disorder) and functional impairment (assessed with the Longitudinal Interval Follow-up Evaluation-Range of Impaired Functioning Tool).

RESULTS

A history of any childhood trauma was reported by 52.7% of the sample (N = 476). Although participants with a history of any childhood trauma presented with greater symptom severity and functional impairment at most study visits, participants with and without a history of any childhood trauma showed similar rates of improvement in symptom severity and functional impairment over the 24 weeks of treatment.

CONCLUSION

This is the first study to explore the association between childhood trauma and treatment outcomes during treatment with lithium or quetiapine in the context of a randomised trial. In Bipolar CHOICE, a history of childhood trauma did not inhibit improvement in symptom severity or functional impairment. Nevertheless, these findings need replication across different settings.

Mixed Methods Thematic Analysis of a Randomised Controlled Trial of Adjunctive Mitochondrial Agents for Bipolar Depression

Objective

There is often a shortfall in recovery following treatment for an episode of bipolar disorder (BD). Exploration of participant's experience provides vital information to enhance statistical outcomes for novel therapy trials. This study used mixed-methods to explore participants' experience of a trial testing N -acetyl cysteine (NAC) and mitochondrially active nutraceuticals for BD depression.

Methods

Case

report forms from a randomised controlled trial (RCT) of BD depression (n = 148) were analysed using a pragmatic adaption of grounded theory and thematic analysis.

Results

Thematic analysis of 148 study participants indicated numerous changes in participant experience over time. For example, perceived environmental stressors reported by participants decreased over the trial in both treatment groups. Quantitative analysis of the themes revealed more positive theme reports in the combination treatment arm compared to the placebo arm and there were more negative themes identified in the placebo arm, compared to the NAC arm.

Conclusion

This approach revealed additional results not elucidated in the primary quantitative analysis. This emphasises the value of mixed-methods research in capturing participants' experiences in RCTs and detecting possible latent benefits and risks. Such methods can detect latent target signals in novel therapy trials conducted in BD and generate novel hypotheses.

Evaluation of an online intervention for improving stroke survivors' health-related quality of life: A randomised controlled trial

BACKGROUND

The aim of this trial was to evaluate the effectiveness of an online health behaviour change intervention-Prevent 2nd Stroke (P2S)-at improving health-related quality of life (HRQoL) amongst stroke survivors at 6 months of follow-up.

METHODS AND FINDINGS

A prospective, blinded-endpoint randomised controlled trial, with stroke survivors as the unit of randomisation, was conducted between March 2018 and November 2019. Adult stroke survivors between 6 and 36 months post-stroke with capacity to use the intervention (determined by a score of ≥4 on the Modified Rankin Scale) and who had access and willingness to use the internet were recruited via mail-out invitations from 1 national and 1 regional stroke registry. Participants completed baseline (n = 399) and 6-month follow-up (n = 356; 89%) outcome assessments via computer-assisted telephone interviewing (CATI). At baseline the sample had an average age of 66 years (SD 12), and 65% were male. Randomisation occurred at the end of the baseline survey; CATI assessors and independent statisticians were blind to group allocation. The intervention group received remote access for a 12-week period to the online-only P2S program (n = 199; n = 28 lost at follow-up). The control group were emailed and posted a list of internet addresses of generic health websites (n = 200; n = 15 lost at follow-up). The primary outcome was HRQoL as measured by the EuroQol Visual Analogue Scale (EQ-VAS; self-rated global health); the outcome was assessed for differences between treatment groups at follow-up, adjusting for baseline measures. Secondary outcomes were HRQoL as measured by the EQ-5D (descriptive health state), diet quality, physical activity, alcohol consumption, smoking status, mood, physical functioning, and independent living. All outcomes included the variable 'stroke event (stroke/transient ischaemic attack/other)' as a covariate, and analysis was intention-to-treat. At 6 months, median EQ-VAS HRQoL score was significantly higher in the intervention group than the control group (85 vs 80, difference 5, 95% CI 0.79-9.21, p = 0.020). The results were robust to the assumption the data were missing at random; however, the results were not robust to the assumption that the difference in HRQoL between those with complete versus missing data was at least 3 points. Significantly higher proportions of people in the intervention group reported no problems with personal care (OR 2.17, 95% CI 1.05-4.48, p = 0.0359) and usual activities (OR 1.66, 95% CI 1.06-2.60, p = 0.0256) than in the control group. There were no significant differences between groups on all other secondary outcomes. The main limitation of the study is that the sample comprises mostly 'well' stroke survivors with limited to no disability.

CONCLUSIONS

The P2S online healthy lifestyle program improved stroke survivors' self-reported global ratings of HRQoL (as measured by EQ-VAS) at 6-month follow-up. Online platforms represent a promising tool to engage and support some stroke survivors.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12617001205325.

The value of compassionate support to address smoking: A qualitative study with people who experience severe mental illness

INTRODUCTION

People experiencing severe mental illness (SMI) smoke at much higher rates than the general population and require additional support. Engagement with existing evidence-based interventions such as quitlines and nicotine replacement therapy (NRT) may be improved by mental health peer worker involvement and tailored support. This paper reports on a qualitative study nested within a peer researcher-facilitated tobacco treatment trial that included brief advice plus, for those in the intervention group, tailored quitline callback counseling and combination NRT. It contextualizes participant life experience and reflection on trial participation and offers insights for future interventions.

METHODS

Qualitative semi-structured interviews were conducted with 29 participants in a randomized controlled trial (intervention group n = 15, control group n = 14) following their 2-month (post-recruitment) follow-up assessments, which marked the end of the "Quitlink" intervention for those in the intervention group. Interviews explored the experience of getting help to address smoking (before and during the trial), perceptions of main trial components including assistance from peer researchers and tailored quitline counseling, the role of NRT, and other support received. A general inductive approach to analysis was applied.

RESULTS

We identified four main themes: (1) the long and complex journey of quitting smoking in the context of disrupted lives; (2) factors affecting quitting (desire to quit, psychological and social barriers, and facilitators and reasons for quitting); (3) the perceived benefits of a tailored approach for people with mental ill-health including the invitation to quit and practical resources; and (4) the importance of compassionate delivery of support, beginning with the peer researchers and extended by quitline counselors for intervention participants. Subthemes were identified within each of these overarching main themes.

DISCUSSION

The findings underscore the enormity of the challenges that our targeted population face and the considerations needed for providing tobacco treatment to people who experience SMI. The data suggest that a tailored tobacco treatment intervention has the potential to assist people on a journey to quitting, and that compassionate support encapsulating a recovery-oriented approach is highly valued.

CLINICAL TRIAL REGISTRATION

The Quitlink trial was registered with ANZCTR (www.anzctr.org.au): ACTRN12619000244101 prior to the accrual of the first participant and updated regularly as per registry guidelines.

Adapting Peer Researcher Facilitated Strategies to Recruit People Receiving Mental Health Services to a Tobacco Treatment Trial

INTRODUCTION

One of the most challenging aspects of conducting intervention trials among people who experience severe mental illness (SMI) and who smoke tobacco, is recruitment. In our parent "QuitLink" randomized controlled trial (RCT), slower than expected peer researcher facilitated recruitment, along with the impact of COVID-19 pandemic restrictions, necessitated an adaptive recruitment response. The objectives of the present study were to: (i) describe adaptive peer researcher facilitated recruitment strategies; (ii) explore the effectiveness of these strategies; (iii) investigate whether recruitment strategies reached different subgroups of participants; and (iv) examine the costs and resources required for implementing these strategies. Finally, we offer experience-based lessons in a Peer Researcher Commentary.

METHODS

People were included in the RCT if they smoked at least 10 cigarettes a day and were accessing mental health support from the project's two partnering mental health organizations in Victoria, Australia. The majority of people accessing these services will have been diagnosed with SMI. Recruitment occurred over 2 years. We began with peer facilitated recruitment strategies delivered face-to-face, then replaced this with direct mail postcards followed by telephone contact. In the final 4 months of the study, we began online recruitment, broadening it to people who smoked and were accessing support or treatment (including from general practitioners) for mental health and/or alcohol or other drug problems, anywhere in the state of Victoria. Differences between recruitment strategies on key participant variables were assessed. We calculated the average cost per enrolee of the different recruitment approaches.

RESULTS

Only 109 people were recruited from a target of 382: 29 via face-to-face (March 2019 to April 2020), 66 from postcards (May 2020 to November 2020), and 14 from online (November to December 2020 and January to March 2021) strategies. Reflecting our initial focus on recruiting from supported independent living accommodation facilities, participants recruited face-to-face were significantly more likely to be living in partially or fully supported independent living (n = 29, <0.001), but the samples were otherwise similar. After the initial investment in training and equipping peer researchers, the average cost of recruitment was AU$1,182 per participant-~US$850. Face-to-face recruitment was the most expensive approach and postcard recruitment the least (AU$1,648 and AU$928 per participant).

DISCUSSION

Peer researcher facilitated recruitment into a tobacco treatment trial was difficult and expensive. Widely dispersed services and COVID-19 restrictions necessitated non-face-to-face recruitment strategies, such as direct mail postcards, which improved recruitment and may be worthy of further research.

CLINICAL TRIAL REGISTRATION

The trial is registered with ANZCTR (www.anzctr.org.au): ACTRN12619000244101 prior to the accrual of the first participant and updated regularly as per registry guidelines. The trial sponsor was the University of Newcastle, NSW, Australia.

A Thermodynamic Model for Interpreting Tryptophan Excitation-Energy-Dependent Fluorescence Spectra Provides Insight Into Protein Conformational Sampling and Stability

It is now over 30 years since Demchenko and Ladokhin first posited the potential of the tryptophan red edge excitation shift (REES) effect to capture information on protein molecular dynamics. While there have been many key efforts in the intervening years, a biophysical thermodynamic model to quantify the relationship between the REES effect and protein flexibility has been lacking. Without such a model the full potential of the REES effect cannot be realized. Here, we present a thermodynamic model of the tryptophan REES effect that captures information on protein conformational flexibility, even with proteins containing multiple tryptophan residues. Our study incorporates exemplars at every scale, from tryptophan in solution, single tryptophan peptides, to multitryptophan proteins, with examples including a structurally disordered peptide, de novo designed enzyme, human regulatory protein, therapeutic monoclonal antibodies in active commercial development, and a mesophilic and hyperthermophilic enzyme. Combined, our model and data suggest a route forward for the experimental measurement of the protein REES effect and point to the potential for integrating biomolecular simulation with experimental data to yield novel insights.

The Added Burden of Personality Disorder on Subsidized Australian Health Service Utilization Among Women With Mental State Disorder

This study aimed to investigate health service utilization among women with mental state disorder only (MSD-PD), mental state disorder plus personality disorder (MSD+PD), and controls in a population-based sample. Women (n = 635) from the Geelong Osteoporosis Study completed mental health assessments and were categorized into groups (MSD-PD, MSD+PD, controls). General practitioner (mental and non-mental health encounters) and specialized mental health service utilization was ascertained from data linkage to the Medicare Benefits Schedule, Australia (01/09/2008-31/12/2012). Negative binomial and binary logistic regression models were employed to assess health service utilization differences between groups. Results indicated that women with MSD+PD had more encounters of non-mental health service utilization than women with MSD-PD and controls. Age significantly modified these relationships: women with MSD+PD and MSD-PD had more encounters of health service utilization at midlife and in the seventh decade of life. No significant differences were found in the frequency of general practitioner mental health service utilization or specialized mental health service utilization between groups. These data suggest that the presence of co-occurring PD is associated with increased health service utilization among women with other common mental health problems. Healthcare providers should be vigilant to the presence of PD when establishing management plans with patients presenting with common mental health problems.

Baseline serum amino acid levels predict treatment response to augmentation with N-acetylcysteine (NAC) in a bipolar disorder randomised trial

N-acetylcysteine (NAC) acts on glutamatergic and redox systems, two systems implicated in the pathophysiology of bipolar disorder (BD). This has led to the investigation of NAC as a potential candidate for the treatment of BD. The aim of this study was to investigate metabolomic markers to identify predictors of NAC response in a cohort of BD participants. This study is a secondary analysis of a 16-week, multi-site, randomized, double-blinded, parallel-group, placebo-controlled trial in BD participants with a current acute depressive episode. This study included trial participants who received either NAC 2000 mg/day, or placebo. Participants (NAC: n = 31, placebo: n = 29) were assessed at baseline and week 16 using the Montgomery Åsberg Depression Rating Scale (MADRS) and were dichotomised into "responders" (MADRS at week 16 < 50% of MADRS at baseline) and "non-responders" (MADRS at week 16 > 50% at baseline). Untargeted gas chromatography-mass spectrometry analysis was performed to analyse baseline levels of 68 serum metabolites. Of the nine metabolites that differentiated placebo and NAC groups, five were amino acids with lower levels in the NAC responder group compared with the NAC non-responders. Further analysis generated a predictive model of MADRS improvement including glycine, norleucine, threonine, proline, phenylalanine, tyrosine, glutamic acid, lysine and leucine (R² = 0.853; adjusted R² = 0.733). This prediction model predicted 85% of the variance in MADRS outcome after adjunctive treatment with NAC. BD participants with lower serum levels of free amino acids at baseline may be more likely to respond to adjunctive treatment with NAC.

Access to and use of internet and social media by low-morbidity stroke survivors participating in a national online secondary prevention trial: A cross-sectional survey (Preprint)

Background

eHealth applications for stroke are a growing area of research that has yielded promising results. However, little is known about how stroke survivors engage with the internet, social media, and other digital technologies on a day-to-day basis.

Objective

This study had three main objectives: to describe the type, frequency, and purpose of technology use among a cohort of low-morbidity stroke survivors; to investigate associations between social media use and participant factors, including sociodemographics, physical function, and independence in activities of daily living; and to investigate associations between stroke-related health risk factors and the use of the internet to search for health and medical information.

Methods

This study is a secondary analysis of data obtained during a national randomized controlled trial—Prevent 2^nd Stroke. The participants were stroke survivors recruited from 2 Australian stroke registries who completed 2 telephone-administered surveys to collect data on demographics and stroke characteristics; health risk factors (diet quality, physical activity, blood pressure medication, alcohol intake, anxiety and depression, and smoking status); physical functioning; independence in activities of daily living; and questions about what technology they had access to, how often they used it, and for what purposes. Participants were eligible if they had no more than a moderate level of disability (modified Rankin score ≤3) and had access to the internet. Multivariable logistic regression was used to assess the associations between social media use and sociodemographics, physical function, and independence in activities of daily living as well as associations between stroke-related health risk factors and the use of the internet to search for health and medical information.

Results

Data from 354 participants were included in the analysis. Approximately 79.1% (280/354) of participants used the internet at least daily, 40.8% (118/289) accessed social media on their phone or tablet daily, and 46.4% (134/289) looked up health and medical information at least monthly. Women were 2.7 times more likely to use social media (adjusted odds ratio 2.65, 95% CI 1.51-4.72), and people aged >75 years were significantly less likely to use social media compared with those aged <55 years (adjusted odds ratio 0.17, 95% CI 0.07-0.44). Health risk factors were not found to be associated with searching for health- or medical-related information.

Conclusions

The internet appears to be a viable platform to engage with stroke survivors who may not be high-morbidity to conduct research and provide information and health interventions. This is important given that they are at high risk of recurrent stroke regardless of their level of disability. Exploring the technology use behaviors and the possibility of eHealth among survivors who experience higher levels of morbidity or disability because of their stroke is an area of research that warrants further study.

N-acetylcysteine (NAC) for methamphetamine dependence: A randomised controlled trial

BACKGROUND

Methamphetamine dependence is a significant global health concern for which there are no approved medications. The cysteine prodrug, N-acetylcysteine (NAC), has been found to ameliorate glutamate dysregulation in addiction, and to reduce craving for methamphetamine and other drugs. We evaluated the efficacy and safety of NAC as a pharmacotherapy for methamphetamine dependence.

METHODS

A parallel double-blind randomised placebo-controlled trial of people dependent on methamphetamine recruited from Geelong, Melbourne and Wollongong, Australia, between July 2018 and December 2019. Participants were randomised to receive either 12 weeks of oral NAC (2400 mg/day) or matched placebo, delivered as a take-home medication. The primary outcome was methamphetamine use, measured in two ways: (a) change in days of use in the past 4 weeks from baseline to weeks 4, 8 and 12, assessed using the Timeline Followback; and (b) methamphetamine-positive oral fluid samples taken weekly. Analyses were intention-to-treat and based on imputed data. Secondary outcomes were craving, severity of dependence, withdrawal severity and psychiatric symptoms (depression, suicidality, hostility and psychotic symptoms). Significance levels were p < 0.025 for primary outcomes and p < 0.01 for secondary outcomes. Adverse events were compared between groups by system organ class. The study was prospectively registered, ACTRN12618000366257.

RESULTS

Participants (N = 153; 59% male, mean [SD] age 38 [8]) were randomised to placebo (n = 77) or NAC (n = 76). Both groups had a median (IQR) of 24 (15-28) days of methamphetamine use in the 4 weeks prior to baseline. Both groups significantly reduced methamphetamine use (mean [SE] reduction of 7.3 [1.2]) days for placebo, 6.8 [1.2] for NAC) but NAC did not reduce days of methamphetamine use more than placebo (group difference of 0.5 days, 97.5% CI -3.4-4.3). There was no significant effect of NAC on methamphetamine-positive oral fluid samples (placebo 79%, NAC 76%; mean difference -2.6, 97.5% CI -12.6-7.4). NAC did not significantly reduce craving, severity of dependence, withdrawal, suicidality, depression, hostility or psychotic symptoms relative to placebo. Adverse events did not differ significantly between placebo and NAC groups.

INTERPRETATION

These findings suggest that take-home oral NAC has no significant effect on methamphetamine use or most clinically related outcomes amongst people who are dependent on the drug.

The Effect of Adjunctive Mangosteen Pericarp on Cognition in People With Schizophrenia: Secondary Analysis of a Randomized Controlled Trial

Background: Cognitive impairment is prevalent and often highly burdensome in people with schizophrenia. The aim of this study was to investigate if mangosteen (Garcinia mangostana Linn.) pericarp extract may be an effective intervention to improve cognitive performance in this population. Methods: This was a secondary analysis of a larger randomized placebo-controlled trial that investigated a 24-weeks intervention of mangosteen pericarp extract supplementation in people diagnosed with schizophrenia. A subset of n = 114 participants with completed cognitive outcomes at follow up were included in this analysis. Using the Cogstate Brief Battery, the following cognitive outcomes were assessed: psychomotor function, attention, visual learning and memory (visual and working). Subgroup analyses investigated whether baseline clinical parameters (baseline cognitive functioning, illness severity and duration, depressive symptoms) moderated the relationship between mangosteen pericarp extract intervention and change in cognitive outcomes. Results: There were no significant between-group changes in any cognitive outcomes assessed. Subgroup analysis based on baseline cognition and clinical characteristics did not reveal any significant between-group difference in change. Conclusions: Mangosteen pericarp extract did not affect cognitive outcomes in people with schizophrenia. Further investigation regarding optimal dosing strategies for mangosteen interventions and the testing of additional cognitive domains may be warranted. Trial Registration: ANZCTR.org.au identifier: ACTRN12616000859482, registered 30 June 3 2016.

POS1268 COVID-19 VACCINE HESITANCY AMONG RHEUMATOLOGY PATIENTS RECEIVING INFLUENZA VACCINE

Background:

Adults with rheumatic diseases are a COVID-19 vulnerable population with potential increased risk for severe infection. COVID-19 vaccines are a key strategy to ending the pandemic. Unfortunately, fears about vaccines, some of which are propagated by misinformation, are common and may prevent or inappropriately delay vaccination. Refusal or uncertainty to get a vaccine despite its availability is known as vaccine hesitancy.

Objectives:

This study aims at defining causes of COVID-19 vaccine hesitancy among rheumatology patients.

Methods:

Between November and December 2020, a cross-sectional survey was completed by rheumatology patients presenting to a large Canadian tertiary-care center for influenza immunization. COVID-19 risk factors, previous COVID-19 infection, the likelihood of getting a future COVID-19 vaccine (scale 0-10), and contextual, individual, and vaccine-specific potential determinants of vaccine hesitancy were assessed. Patients were classified into 5 groups based on how likely they were to get a future COVID-19 vaccine (0= not likely at all; 2.5= unlikely; 5= intermediate; 7.5= likely; 10= highly likely). A machine learning approach (XgBoost) was used to fit univariate models for a multi-class correlation.

Results:

157 rheumatology patients completed the survey. Most were females (n=112, 71%) with a mean age of 54.6 (standard deviation 17.9). The majority (73%) had tertiary-education, and 46% were employed at the time of the survey. The most common rheumatology diagnoses were rheumatoid arthritis (n=90, 58%), systemic lupus erythematosus/vasculitis (n=41, 26%) and spondyloarthropathies (n=39, 25%). Most patients were on immunosuppressors (n=93, 59%). Only half (n=85, 54%) were highly likely to accept a future COVID vaccine, 17% (n=26) likely, 19% (n=30) intermediate, 6% (n=10) unlikely, and 4% (n=6) not likely at all. One hundred thirty-five patients (86%) previously received the flu vaccine, whereas 6% (n=10) previously rejected it. Only three patients were previously diagnosed with COVID-19 (2%) one of whom was hospitalized. Eighty-seven patients (56%) considered that the COVID-19 vaccine should be mandatory, and 101 (65%) that they should receive it. Most respondents were somewhat concerned about receiving a future COVID-19 vaccine (n=116, 76%) despite that 65% believed that vaccines benefits outweighed their risks. Almost all, (n=145, 96%) believed that governmental decisions about vaccines are in the best interest of the population, while less than half (n=70, 45%) were confident that pharmaceutical companies would provide safe and effective vaccines. One hundred participants (65%) denied feeling social pressure to get the vaccine, and 55% (n=81) were willing to pay for the vaccine. Feeling social pressure about getting a COVID-19 vaccine, having severe concerns about receiving a future COVID-19 vaccine, distrust in pharmaceutical companies, lower education, and doubts of whether vaccines benefits outweigh their risks, were negatively associated with COVID vaccine acceptance.

Conclusion:

Forty six percent of rheumatology patients being immunized against influenza showed at least some hesitancy towards COVID-19 vaccination. Multiple contextual, individual, and vaccine-related factors may contribute. Targeted educational strategies, including producing and communicating data on vaccine safety, may help promote vaccine uptake in this potentially vulnerable population.

Disclosure of Interests:

None declared

Cognitive insight, medication adherence and methamphetamine cessation in people enrolled in a pharmacotherapy trial for methamphetamine use

BACKGROUND

The current study examined correlates of cognitive insight in people enrolled in a methamphetamine pharmacotherapy trial; whether cognitive insight at the start of the trial predicted medication adherence and reductions in methamphetamine use during the trial; and, whether insight would remain stable over the trial or improve with reductions in methamphetamine use.

METHODS

A subset of people enrolled in a 12-week randomised placebo-controlled pharmacotherapy trial for methamphetamine dependence completed the Beck Cognitive Insight Scale, comprising subscales for Self-Reflection and Self-Certainty, at baseline (n = 152) and at week 12 (n = 79). Medication adherence was expressed as the percentage of non-missed doses measured using eCAP™ technology. Methamphetamine use days were assessed using the Timeline Followback.

RESULTS

At baseline, greater Self-Reflection was correlated with more severe methamphetamine withdrawal, and hostility, whereas Self-Certainty was correlated with less education and longer duration of methamphetamine use. No relationship was found between BCIS subscales at baseline and medication adherence (Self-Reflection b[SE] = -0.73 [0.43] p = .09; Self-Certainty b[SE] = -0.31 [0.48] p = .52,). Neither BCIS subscale was predictive of reduced methamphetamine use at 12 weeks (Self-Reflection b[SE] = 0.001 [0.01] p = .95 Self-Certainty b[SE] = -0.003 [0.01], p = .74). Self-Reflection decreased over the trial (t = 3.42, p = .001) but this was unrelated to change in methamphetamine use (Self-Reflection, b[SE] = -1.68 [1.16] p = .15) Change in methamphetamine use was found to be a significant predictor of Self-Certainty at 12 weeks (b [SE] = -2.71 [1.16] p = .02).

CONCLUSIONS

We found no evidence that cognitive insight predicted medication adherence or methamphetamine reduction in people engaged in this trial. Ongoing or increased methamphetamine use predicted increased Self-Certainty at 12 weeks.

Influence of childhood trauma on the treatment outcomes of pharmacological and/or psychological interventions for adolescents and adults with bipolar disorder: protocol for a systematic review and meta-analysis

INTRODUCTION

Despite available pharmacological and psychological treatments, remission rates for bipolar disorder remain relatively low. Current research implicates the experience of childhood trauma as a potential moderator of poor treatment outcomes among individuals with bipolar disorder. To date, the evidence reporting the influence of childhood trauma on the treatment outcomes of pharmacological and/or psychological interventions for adolescents and adults with bipolar disorder has not been systematically reviewed.

METHOD AND ANALYSIS

MEDLINE Complete, Embase, PsycINFO and the Cochrane Central Register of Controlled Trials will be searched to identify randomised and nonrandomised studies of pharmacological and/or psychological interventions for bipolar disorder, which also assessed childhood trauma. To be eligible for inclusion, studies must have been conducted with adolescents or adults (≥10 years). Data will be screened and extracted by two independent reviewers. The methodological quality of the included studies will be assessed with the Cochrane Collaboration's Risk of Bias tool and the Newcastle-Ottawa Scale. If deemed viable, a meta-analysis will be conducted using a random effects model. Heterogeneity of evidence will be estimated with the I² statistics.

ETHICS AND DISSEMINATION

This systematic review will use only previously published data. Therefore, ethical approval is not required. The results will be written in concordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines, published in peer-reviewed journals and presented at relevant conferences.

PROSPERO REGISTRATION NUMBER

CRD42020201891.

Adjunctive Garcinia mangostana Linn. (Mangosteen) Pericarp for Schizophrenia: A 24-Week Double-blind, Randomized, Placebo Controlled Efficacy Trial: Péricarpe d'appoint Garcinia mangostana Linn (mangoustan) pour la schizophrénie : un essai d'efficacité de 24 semaines, à double insu, randomisé et contrôlé par placebo

OBJECTIVES

Garcinia mangostana Linn. ("mangosteen") pericarp contains bioactive compounds that may target biological pathways implicated in schizophrenia. We conducted a double-blind randomized placebo-controlled trial evaluating the efficacy of adjunctive mangosteen pericarp, compared to placebo, in the treatment of schizophrenia.

METHODS

People diagnosed with schizophrenia or schizoaffective disorder (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition), recruited across 2 sites (Brisbane and Victoria, Australia), were randomized to receive 24 weeks of adjunctive mangosteen pericarp (1,000 mg/day) or matched placebo. The primary outcome measure was the Positive and Negative Symptom Scale total score. Secondary outcomes included positive and negative symptoms, general psychopathology, clinical global severity and improvement, participant reported overall improvement, depressive symptoms, functioning, quality of life, and safety data at 24 and 28 weeks (4 weeks postdiscontinuation). Data were collected from July 2016 to February 2019.

RESULTS

Baseline assessments were conducted on 148 people (mangosteen = 74, placebo = 74); data analyses were conducted on 136 (92%) participants with postbaseline data. The treatment group had significantly higher symptom severity compared to placebo, and both groups significantly improved on all symptom, functioning, and quality of life measures over time. No between-group differences were found for the rate of change between baseline and 24 or 28 weeks.

CONCLUSION

Despite promising preclinical and clinical work, our results do not support mangosteen pericarp extract as an adjunctive treatment for schizophrenia or schizoaffective disorder.

Replication of Marek's disease vaccines in turkey embryos and their effect on TLR-3 and IFN-γ transcripts

Understanding the pathogenesis of herpesvirus of turkeys (HVT) in its natural host is necessary before recombinant HVT (rHVT) can be used efficiently in turkey flocks. The objectives of this study were to evaluate when commercial turkey flocks get infected with wild type HVT, to study replication of HVT (conventional and recombinant rHVT-Newcastle disease, rHVT-ND) and other Marek's disease (MD) vaccines (SB-1 and CVI988) in turkey embryonic tissues, and to evaluate the expression of TLR-3 and IFN-γ in the lung and spleen of one-day-old turkeys after in ovo vaccination with MD vaccines. Our results demonstrated that commercial turkeys got exposed to wild type HVT within the first days of life; therefore, there is a potential of interaction between wild type HVT and rHVT when administered at day of age. On the other hand, all evaluated vaccines (especially HVT and rHVT-ND) replicated very well in turkey embryonic tissues. In ovo vaccination with HVT and CVI988 increased transcription of TLR-3 in the spleen of one-day-old turkeys. However, no effect on the transcription of TLR-3 or IFN-γ in the lungs and IFN-γ in the spleen in newly hatched turkeys was detected in the present study. Because of the limitations of evaluated genes, timepoints, and studied tissues, future studies are warranted to better understand the effect of MD vaccines on the turkey embryo immune responses.RESEARCH HIGHLIGHTS Commercial turkey flocks get infected with wild type HVT within the first days of life.HVT and rHVT replicates readily in turkey embryonic tissues.SB-1 and CVI988 also replicate in turkey embryonic tissues, but at lower rates than HVT and rHVT.HVT and CVI988 increase transcription of TLR-3 in the spleen.

Systematic review and meta-analysis of the role of personality disorder in randomised controlled trials of pharmacological interventions for adults with mood disorders

BACKGROUND

Personality disorder (PD) may affect the efficacy of pharmacological interventions for mood disorders, but the extent to which this occurs is uncertain. We aimed to examine the available published evidence concerning the role of PD in pharmacological treatment outcomes of randomised controlled trials (RCTs) for adults with mood disorders (i.e. depressive and bipolar spectrum disorders).

METHODS

A systematic search of Cochrane Central Register of Controlled Clinical Trials, PubMed, EMBASE, PsycINFO, CINAHL Complete, and Google Scholar databases was undertaken to identify studies of interest. Data were independently extracted by two reviewers. The Cochrane Risk of Bias tool was used to assess methodological quality and risk of bias. A random effects model was utilised and statistical heterogeneity was assessed using the I² statistic. This systematic review was registered with PROSPERO (CRD42018089279) and the protocol is published.

RESULTS

The search yielded 11,640 studies. Subsequent to removing duplicates, 9657 studies were screened at title and abstract stage and 1456 were assessed at full-text stage. Eighteen studies met criteria for inclusion in this review. Meta-analysis did not reveal a significant difference between groups for treatment outcome (standardised mean difference 0.22 [-0.09, 0.54]; I²: 69%, p=0.17) and remission (risk ratio 0.84 [0.64, 1.11]; I²: 51%, p=0.22).

LIMITATIONS

This review was limited by lack of studies on bipolar disorder.

CONCLUSION

PD comorbidity does not appear to affect treatment efficacy of pharmacological interventions for adults with mood disorders.

An online survey of informal caregivers' unmet needs and associated factors

PURPOSE/OBJECTIVE

The purpose of this study was to assess the frequency of unmet needs of carers among a convenience sample of carers, and the participant factors associated with unmet needs, to inform the development of interventions that will support a range of caregivers. The aims of this study were to: (1) assess the most frequently reported moderate-high unmet needs of caregivers; and (2) examine the age, gender, condition of the care recipient, and country variables associated with types of unmet needs reported by informal caregivers.

RESEARCH METHOD/DESIGN

An online cross-sectional survey among informal caregivers in English-speaking countries was conducted. Self-reported unmet needs were assessed using an unmet needs measure with the following five unmet needs domains: (1) Health information and support for care recipient; (2) Health service management; (3) Communication and relationship; (4) Self-care; and (5) Support services accessibility. Informal caregivers were asked "In the last month, what was your level of need for help with…", and the ten highest ranked moderate-high unmet needs presented as ranked proportions. Logistic regression modelling examined the factors associated with types of unmet needs.

RESULTS

Overall, 457 caregivers were included in the final analysis. Seven of the ten highest ranked unmet needs experienced by caregivers in the last month were in the Self-care domain, including "Reducing stress in your life" (74.1%). Significant associations were found between younger caregiver age (18-45 years) and reporting moderate-high unmet needs in Health Information and support for care recipient, Health service management, and Support services accessibility (all p's = <0.05).

CONCLUSIONS/IMPLICATIONS

Caregivers are not experiencing significant differences in unmet needs between countries and caree/care recipient conditions, suggesting that general interventions could be developed to support a range of caregivers across countries. Increased awareness of informal caregivers' unmet needs, particularly for younger caregivers, among health care providers may improve support provision to caregivers.

Insight in substance use disorder: A systematic review of the literature

Insight refers to a person's understanding of themselves and the world around them. Recent literature has explored people's insight into their substance use disorder (SUD) and how this is linked to treatment adherence, abstinence rates, and comorbid mental health symptoms. The aim of this systematic review was to synthesise and critically examine the existing literature on insight in SUD. Five academic databases (Medline, PsychINFO, SCOPUS, CINAHL, Web of Science) were searched for key terms related to insight and substance use. Included studies were on humans aged 18 years or over with SUD that examined the relationship between substance use and insight using a quantifiable measure of insight. Of 10,067 identified papers, 20 met the inclusion criteria, employing 13 different measures of insight. The most commonly used measure was the Hanil Alcohol Insight Scale (HAIS) which was the only measure designed for a substance use population and was specific to alcohol use. Based on a pooled sample from five studies (n = 585), 57% of participants had poor insight, 36% had fair insight, and 7% had good insight on the HAIS. Better insight was generally related to negative consequences from substance use, better treatment adherence and maintaining abstinence. Insight appears to be an important factor to consider within SUD. Exploring the most appropriate way to measure insight and assess its role in SUD has implications for intervention design, and engaging and maintaining people with SUD in treatment.