Suicide postvention for staff and students on university campuses: a scoping review

OBJECTIVE

To examine current knowledge about suicide bereavement and postvention interventions for university staff and students.

DESIGN

Scoping review.

DATA SOURCES AND ELIGIBILITY

We conducted systematic searches in 12 electronic databases (PubMed, PsycINFO, MEDLINE, CINAHL, Africa-Wide Information, PsycARTICLES, Health Source: Nursing/Academic Edition, Academic Search Premier, SocINDEX through the EBSCOHOST platform; Cochrane Library, Web of Science, SCOPUS), hand searched lists of references of included articles and consulted with library experts during September 2021 and June 2022. Eligible studies were screened against the inclusion criteria independently by two reviewers. Only studies published in English were included.

DATA EXTRACTION AND SYNTHESIS

Screening was conducted by two independent reviewers following a three-step article screening process. Biographical data and study characteristics were extracted using a data extraction form and synthesised.

RESULTS

Our search strategy identified 7691 records from which 3170 abstracts were screened. We assessed 29 full texts and included 17 articles for the scoping review. All studies were from high-income countries (USA, Canada, UK). The review identified no postvention intervention studies on university campuses. Study designs were mostly descriptive quantitative or mixed methods. Data collection and sampling were heterogeneous.

CONCLUSION

Staff and students require support measures due to the impact of suicide bereavement and the unique nature of the university context. There is a need for further research to move from descriptive studies to focus on intervention studies, particularly at universities in low-income and middle-income countries.

'connEcted caesarean section': creating a virtual link between MOthers and their infanTs to ImprOve maternal childbirth experieNce - study protocol for a PILOT trial (e-motion-pilot)

INTRODUCTION

One-third of mothers rate their childbirth as traumatic. The prevalence of childbirth-related post-traumatic stress disorder (CB-PTSD) is 4.7%. Skin-to-skin contact is a protective factor against CB-PTSD. However, during a caesarean section (CS), skin-to-skin contact is not always feasible and mothers and infants are often separated. In those cases, there is no validated and available solution to substitute this unique protective factor. Based on the results of studies using virtual reality and head-mounted displays (HMDs) and studies on childbirth experience, we hypothesise that enabling the mother to have a visual and auditory contact with her baby could improve her childbirth experience while she and her baby are separated. To facilitate this connection, we will use a two-dimensional 360° camera filming the baby linked securely to an HMD that the mother can wear during the end of the surgery.

METHODS AND ANALYSIS

This study protocol describes a monocentric open-label controlled pilot trial with minimal risk testing the effects of a visual and auditory contact via an HMD worn by the mother airing a live video of her newborn compared with treatment-as-usual in 70 women after CS. The first 35 consecutive participants will be the control group and will receive the standard care. The next 35 consecutive participants will have the intervention. The primary outcome will be differences in maternal childbirth experience (Childbirth Experience Questionnaire 2) at 1-week postpartum between the intervention and control groups. Secondary outcomes will be CB-PTSD symptoms, birth satisfaction, mother-infant bonding, perceived pain and stress during childbirth, maternal anxiety and depression symptoms, anaesthesiological data and acceptability of the procedure.

ETHICS AND DISSEMINATION

Ethics approval was granted by the Human Research Ethics Committee of the Canton de Vaud (study number 2022-00215). Dissemination of results will occur via national and international conferences, peer-reviewed journals, public conferences and social media.

TRIAL REGISTRATION NUMBER

NCT05319665.

Staging model of PTSD: a strategy for the implementation of precision medicine in military settings

Biomarkers have been of considerable interest in military medicine as a strategy to identify objective measures of resilience in the context of the cumulative trauma exposure of combat as well defining the emerging neurobiological dysregulation associated with post-traumatic stress disorder (PTSD). This body of work has been driven by the imperative of developing strategies to optimally manage the long-term health outcomes of personnel and finding novel treatment approaches. However, the challenge of defining the relevant phenotypes of PTSD and in the context of the multiplicity of biological systems of interest has hampered the identification of biomarkers that have clinical utility. One key strategy to improve the utility of precision medicine in military settings is to use a staging approach to define the relevant phenotypes. A staging model of PTSD captures the progression of the disorder and the transitions from being at risk to subsyndromal disorder and the path to chronic disorder.A staging approach addresses the longitudinal course of PTSD and the fluidity of the disorder across time. Staging describes how symptoms evolve into more stable diagnostic syndromes and the stepwise changes in clinical status which is key to the identification of phenotypes that can be tied to relevant biomarkers. When a population is exposed to a trauma, the individuals will be at different stages in the emergence of risk and the development of PTSD. The staging approach provides a method of capturing the matrix of phenotypes that need to be demarcated to study the role of multiple biomarkers. This paper forms part of the Special issue of BMJ Military Health dedicated to personalised digital technology for mental health in the armed forces.

New living evidence resource of human and non-human studies for early intervention and research prioritisation in anxiety, depression and psychosis

In anxiety, depression and psychosis, there has been frustratingly slow progress in developing novel therapies that make a substantial difference in practice, as well as in predicting which treatments will work for whom and in what contexts. To intervene early in the process and deliver optimal care to patients, we need to understand the underlying mechanisms of mental health conditions, develop safe and effective interventions that target these mechanisms, and improve our capabilities in timely diagnosis and reliable prediction of symptom trajectories. Better synthesis of existing evidence is one way to reduce waste and improve efficiency in research towards these ends. Living systematic reviews produce rigorous, up-to-date and informative evidence summaries that are particularly important where research is emerging rapidly, current evidence is uncertain and new findings might change policy or practice. Global Alliance for Living Evidence on aNxiety, depressiOn and pSychosis (GALENOS) aims to tackle the challenges of mental health science research by cataloguing and evaluating the full spectrum of relevant scientific research including both human and preclinical studies. GALENOS will also allow the mental health community-including patients, carers, clinicians, researchers and funders-to better identify the research questions that most urgently need to be answered. By creating open-access datasets and outputs in a state-of-the-art online resource, GALENOS will help identify promising signals early in the research process. This will accelerate translation from discovery science into effective new interventions for anxiety, depression and psychosis, ready to be translated in clinical practice across the world.

Assessing violence risk in first-episode psychosis: external validation, updating and net benefit of a prediction tool (OxMIV)

BACKGROUND

Violence perpetration is a key outcome to prevent for an important subgroup of individuals presenting to mental health services, including early intervention in psychosis (EIP) services. Needs and risks are typically assessed without structured methods, which could facilitate consistency and accuracy. Prediction tools, such as OxMIV (Oxford Mental Illness and Violence tool), could provide a structured risk stratification approach, but require external validation in clinical settings.

OBJECTIVES

We aimed to validate and update OxMIV in first-episode psychosis and consider its benefit as a complement to clinical assessment.

METHODS

A retrospective cohort of individuals assessed in two UK EIP services was included. Electronic health records were used to extract predictors and risk judgements made by assessing clinicians. Outcome data involved police and healthcare records for violence perpetration in the 12 months post-assessment.

FINDINGS

Of 1145 individuals presenting to EIP services, 131 (11%) perpetrated violence during the 12 month follow-up. OxMIV showed good discrimination (area under the curve 0.75, 95% CI 0.71 to 0.80). Calibration-in-the-large was also good after updating the model constant. Using a 10% cut-off, sensitivity was 71% (95% CI 63% to 80%), specificity 66% (63% to 69%), positive predictive value 22% (19% to 24%) and negative predictive value 95% (93% to 96%). In contrast, clinical judgement sensitivity was 40% and specificity 89%. Decision curve analysis showed net benefit of OxMIV over comparison approaches.

CONCLUSIONS

OxMIV performed well in this real-world validation, with improved sensitivity compared with unstructured assessments.

CLINICAL IMPLICATIONS

Structured tools to assess violence risk, such as OxMIV, have potential in first-episode psychosis to support a stratified approach to allocating non-harmful interventions to individuals who may benefit from the largest absolute risk reduction.

Improving the efficacy of exposure therapy using projection-based augmented reality for the treatment of cockroach phobia: a randomised clinical trial protocol

INTRODUCTION

In vivo exposure is the treatment of choice for specific phobia (SP), but this technique presents limitations related to access and acceptability. Augmented reality (AR) offers advantages like maximising strategies such as 'variability' (varying stimuli, durations, levels of intensity or the order of the items), control by the therapist, or 'exposure to multiple contexts', which can produce positive effects in terms of fear renewal and generalisation of the results. The aim of this study is to test the efficacy of varying the phobic stimuli during treatment with AR: using multiple stimuli (MS) versus a single stimulus (SS) in participants with SP.

METHODS AND ANALYSIS

Participants (N=80) with a diagnosis of an SP of cockroaches will be randomised into two conditions: (1) projection-based AR exposure therapy with MS (P-ARET MS); (2) P-ARET with an SS (P-ARET SS). The measures are related to the efficacy results (fear, avoidance and negative thoughts, performance on the behavioural avoidance test (BAT) and preferences). The primary outcome measure is the BAT, and the secondary outcome measures are the BAT through AR, Fear of Cockroaches Questionnaire, Cockroach Phobia Beliefs Questionnaire, Fear and Avoidance Scales Patient's Improvement Scale, and Beck Depression Inventory Second Edition. Five evaluation moments will be included: preintervention, postintervention, and 1-month, 6-month, and 12-month follow-ups. The treatment will follow the guidelines of the 'one-session treatment'. Student's t-tests to compare the two groups on the post-test will be applied. In addition, two-way analysis of variances with repeated measures in one of the two factors (pretest, post-test and follow-ups) will be carried out to compare intragroup differences.

ETHICS AND DISSEMINATION

The Universitat Jaume I Ethics Committee (Castellón, Spain) granted approval for the study (CD/64/2019). Dissemination will include publications and presentations at national and international conferences.

TRIAL REGISTRATION NUMBER

NCT04563403.

Effectiveness of a projection-based augmented reality exposure system in treating cockroach phobia: study protocol of a randomised controlled trial

BACKGROUND

Despite being the treatment of choice for phobic disorders, in vivo exposure treatment (IVET) presents some important limitations related mainly to low acceptance and high drop-out rates. Augmented reality (AR) technologies can help to overcome these limitations. Evidence supports the use of AR in exposure treatment for small animal phobia. A new projection-based AR exposure treatment system (P-ARET) that offers the possibility of projecting the animals in a natural and non-intrusive environment has been developed. There are no randomised controlled trials (RCTs) available that have tested the efficacy of this system in cockroach phobia. This paper aims to present the protocol of an RCT that evaluates the efficacy of the P-ARET, versus an IVET group and a waiting list control group (WL), in carrying out exposure treatment for cockroach phobia.

METHODS/DESIGN

Participants will be randomly allocated to one of three conditions: (1) P-ARET, (2) IVET and (3) WL. Both treatment conditions will follow the 'one-session treatment' guidelines. As a diagnostic measure, the Anxiety Disorders Interview Schedule for Diagnostic and Statistical Manual for Mental Health Disorders-Version 5 will be used. The Behavioral Avoidance Test will be used as the primary outcome measure. Secondary outcome measures will include an attentional biases task (measured using eye-tracking technology), the Fear of Cockroaches Questionnaire, Cockroach Phobia Beliefs Questionnaire, Fear and Avoidance Scales, Beck Depression Inventory second edition, Disgust Propensity and Sensitivity Scale-Revised-12, State-Trait Anxiety Inventory, Clinician Severity Scale, and Expectation and Satisfaction with the Treatment Scale. The evaluation protocol will include pretreatment and post-treatment evaluations and 1, 6 and 12 months of follow-ups. Intention-to-treat and per-protocol analyses will be performed.

ETHICS AND DISSEMINATION

This study has been approved by the Ethics Committee of Universitat Jaume I (Castellón, Spain; 13 December 2019). The results of the presented RCT will be disseminated in presentations at international scientific meetings and peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

NCT04563390.

Effect of environmental enrichment on relapse rates in patients with severe alcohol use disorder: protocol for a randomised controlled trial

INTRODUCTION

Alcohol use disorder (AUD) ranks among the most prevalent psychiatric disorders worldwide. Despite current treatments, more than half of patients relapse within weeks after treatment. In animal models, exposure to environmental enrichment (EE) has been shown to be a promising approach to reduce relapse. However, controlled, multimodal EE is difficult to transpose to humans. To address this gap, this study aims at assessing the effectiveness of exposure to a newly designed EE protocol during AUD treatment in reducing relapse to alcohol use. Our EE will allow an enhancement of the standard intervention, and will combine several promising enrichment factors identified in the literature-physical activity, cognitive stimulation, mindfulness and virtual reality (VR).

METHODS AND ANALYSIS

A randomised controlled trial involving 135 participants receiving treatment for severe AUD will be conducted. Patients will be randomised to an intervention enhancement group or a control group. The enhanced intervention will consist of six 40-min sessions of EE spread over 9 days. During the first 20 min of these sessions, patients will practise mindfulness in multisensory VR, in virtual environments designed to practise mindfulness and use it to regulate craving induced by virtual cues or stress. Then, participants will practise indoor cycling combined with cognitive training exercises. The control group will undergo standard management for AUD. The primary outcome is relapse assessed at 2 weeks after treatment, using a questionnaire and biological indicators. Relapse will be defined as drinking at least five drinks per occasion or drinking at least five times a week. It is predicted that the group receiving the EE intervention will have a lower relapse rate than the control group. The secondary outcomes are relapse at 1 month and 3 months after treatment, craving and drug-seeking behaviour, mindfulness skills acquisition and the effect of the intervention enhancement on the perceived richness of the daily environment, assessed by questionnaires and neuropsychological tasks.

ETHICS AND DISSEMINATION

All participants have to give written informed consent to the investigator. This study is approved by the Ethics Committee Nord Ouest IV of Lille (reference number 2022-A01156-37). Results will be disseminated through presentations, peer-reviewed journals and seminar conferences. All information on ethical considerations and open science practices can be accessed at https://osf.io/b57uj/ TRIAL REGISTRATION NUMBER: NCT05577741.

Study protocol of an open-label proof-of-concept trial examining the safety and clinical efficacy of psilocybin-assisted therapy for veterans with PTSD

INTRODUCTION

Psilocybin-assisted therapy has shown significant promise in treating the cluster of mood and anxiety symptoms that comprise post-traumatic stress disorder (PTSD) but has yet to be tested specifically in this condition. Furthermore, current pharmacological and psychotherapeutic treatments for PTSD are difficult to tolerate and limited in efficacy, especially in the US Military Veteran (USMV) population. This open-label pilot study will examine the safety and efficacy of two psilocybin administration sessions (15 mg and 25 mg), combined with psychotherapy, among USMVs with severe, treatment resistant PTSD.

METHODS AND ANALYSIS

We will recruit 15 USMVs with severe, treatment resistant PTSD. Participants will receive one low dose (15 mg) and one moderate/high dose (25 mg) of psilocybin in conjunction with preparatory and post-psilocybin therapy sessions. The primary safety outcome will be the type, severity and frequency of adverse events and suicidal ideation/behaviour, as measured by the Columbia Suicide Severity Rating Scale. The primary outcome measure for PTSD will be the Clinician Administered PTSD Scale-5. The primary endpoint will be 1 month following the second psilocybin administration session, and the total follow-up time will be 6 months.

ETHICS AND DISSEMINATION

All participants will be required to provide written informed consent. The trial has been authorised by the Ohio State University Institutional Review Board (study number: 2022H0280). Dissemination of results will occur via a peer-reviewed publication and other relevant media.

TRIAL REGISTRATION NUMBER

NCT05554094.

Risk of death by suicide following self-harm presentations to healthcare: development and validation of a multivariable clinical prediction rule (OxSATS)

BACKGROUND

Assessment of suicide risk in individuals who have self-harmed is common in emergency departments, but is often based on tools developed for other purposes.

OBJECTIVE

We developed and validated a predictive model for suicide following self-harm.

METHODS

We used data from Swedish population-based registers. A cohort of 53 172 individuals aged 10+ years, with healthcare episodes of self-harm, was split into development (37 523 individuals, of whom 391 died from suicide within 12 months) and validation (15 649 individuals, 178 suicides within 12 months) samples. We fitted a multivariable accelerated failure time model for the association between risk factors and time to suicide. The final model contains 11 factors: age, sex, and variables related to substance misuse, mental health and treatment, and history of self-harm. Transparent reporting of a multivariable prediction model for individual prognosis or diagnosis guidelines were followed for the design and reporting of this work.

FINDINGS

An 11-item risk model to predict suicide was developed using sociodemographic and clinical risk factors, and showed good discrimination (c-index 0.77, 95% CI 0.75 to 0.78) and calibration in external validation. For risk of suicide within 12 months, using a 1% cut-off, sensitivity was 82% (75% to 87%) and specificity was 54% (53% to 55%). A web-based risk calculator is available (Oxford Suicide Assessment Tool for Self-harm or OxSATS).

CONCLUSIONS

OxSATS accurately predicts 12-month risk of suicide. Further validations and linkage to effective interventions are required to examine clinical utility.

CLINICAL IMPLICATIONS

Using a clinical prediction score may assist clinical decision-making and resource allocation.

Exploring gender dysphoria and related outcomes in a prospective cohort study: protocol for the Swedish Gender Dysphoria Study (SKDS)

INTRODUCTION

There has been a drastic increase in the reported number of people seeking help for gender dysphoria in many countries over the last two decades. Yet, our knowledge of gender dysphoria and related outcomes is restricted due to the lack of high-quality studies employing comprehensive approaches. This longitudinal study aims to enhance our knowledge of gender dysphoria; different aspects will be scrutinised, focusing primarily on the psychosocial and mental health outcomes, prognostic markers and, secondarily, on the underlying mechanisms for its origin.

METHODS AND ANALYSIS

The Swedish Gender Dysphoria Study is an ongoing multicentre longitudinal cohort study with 501 registered participants with gender dysphoria who are 15 years old or older. Participants at different phases of their clinical evaluation process can enter the study, and the expected follow-up duration is three years. The study also includes a comparison group of 458 age- and county-matched individuals without gender dysphoria. Data on the core outcomes of the study, which are gender incongruence and experienced gender dysphoria, body satisfaction and satisfaction with gender-affirming treatments, as well as other relevant outcomes, including mental health, social functioning and life satisfaction, are collected via web surveys. Two different research visits, before and after starting on gender-affirming hormonal treatment (if applicable), are planned to collect respective biological and cognitive measures. Data analysis will be performed using appropriate biostatistical methods. A power analysis showed that the current sample size is big enough to analyse continuous and categorical outcomes, and participant recruitment will continue until December 2022.

ETHICS AND DISSEMINATION

The ethical permission for this study was obtained from the Local Ethical Review Board in Uppsala, Sweden. Results of the study will be presented at national and international conferences and published in peer-reviewed journals. Dissemination will also be implemented through the Swedish Gender Dysphoria Study network in Sweden.

Feasibility study to evaluate capabilities for conducting psychiatric clinical research within the Rwandan mental healthcare system

OBJECTIVE

To evaluate the feasibility of conducting a large clinical trial within the Rwandan mental healthcare system that would establish the safety, efficacy and benefit of paliperidone palmitate once-monthly (PP1M) and once-every-3-months (PP3M) long-acting injectable formulations in adults with schizophrenia.

STUDY DESIGN

An open-label, prospective feasibility study.

SETTING/PARTICIPANTS

33 adult patients with schizophrenia were enrolled at 3 sites across Rwanda.

INTERVENTIONS

The study design included 3 phases of treatment: an oral run-in to establish tolerability to risperidone (1 week), lead-in treatment with flexibly dosed PP1M to identify a stable dose (17 weeks) and maintenance treatment with PP3M (24 weeks).

PRIMARY AND SECONDARY OUTCOME MEASURES

Feasibility endpoints included compliance with governmental and institutional requirements, acceptable supply chain delivery and proper onsite administration of risperidone/PP1M/PP3M, adequate site infrastructure, adequate training of clinical staff and successful completion of study procedures and scales. A variety of study scales were administered to assess outcomes relevant to patients, caregivers, clinicians and payers in Rwanda and other resource-limited settings.

RESULTS

This study was terminated early by the sponsor because certain aspects of study conduct needed to be addressed to maintain Good Clinical Practice requirements and meet regulatory standards. Results identified areas for improvement in study execution, including study governance, site infrastructure, study preparation and conduct of procedures, study budget and study assessments. Despite the identification of areas in need of adjustment, none of these limitations were considered insurmountable.

CONCLUSIONS

This work was designed to strengthen global research in schizophrenia by building the capacity of researchers to prepare and conduct pharmaceutical trials in resource-limited settings. Although the study was ended early, modifications motivated by the results will facilitate the successful design and completion of more comprehensive studies, including an ongoing, follow-up interventional trial of PP1M/PP3M in a larger population of patients in Rwanda.

TRIAL REGISTRATION NUMBER

NCT03713658.

Modified cue exposure for adolescents with binge eating behaviour: study protocol of a randomised pilot trial called EXI(ea)T

INTRODUCTION

Binge eating (BE) behaviour is highly prevalent in adolescents, and can result in serious metabolic derangements and overweight in the long term. Weakened functioning of the behavioural inhibition system is one potential pathway leading to BE. Food cue exposure focusing on expectancy violation (CE_EV) is a short intervention for BE that has proven effective in adults but has never been tested in adolescents. Thus, the current randomised pilot trial evaluates the feasibility of CE_EV for adolescents and its efficacy in reducing eating in the absence of hunger (EAH) of binge food items.

METHODS AND ANALYSIS

The trial will include N=76 female adolescents aged between 13 and 20 years with a diagnosis of bulimia nervosa, binge eating disorder (BED) or their subthreshold forms based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Participants will be randomly assigned to two sessions of CE_EV or behavioural analysis (BA), a classical cognitive-behavioural therapy-based intervention. The primary endpoint is the change in EAH measured according to ad libitum consumption of personally preferred binge food in a bogus taste test at post-test based on the intention-to-treat population. Key secondary endpoints are changes in EAH of standardised binge food at post-test, in EAH at 3-month follow-up (FU) and in food craving after induction of food cue reactivity at post-test and FU. To identify further valid outcome parameters, we will assess effects of CE_EV compared with BA on global ED psychopathology, BE frequency within the last 28 days, body weight, response inhibition and emotion regulation abilities. Treatment groups will be compared using analysis of covariance with intervention as fixed factor and body mass index at baseline as covariate.

ETHICS AND DISSEMINATION

This clinical trial has been approved by the Ethics Review Committee of the Medical Association of Rhineland-Palatinate and the Medical Faculty of the Ruhr-University Bochum. The collected data will be disseminated locally and internationally through publications in relevant peer-reviewed journals and will be presented at scientific and clinical conferences. Participants data will only be published in an anonymised form.

TRIAL REGISTRATION NUMBER

DRKS00024009.

Linguistic profile automated characterisation in pluripotential clinical high-risk mental state (CHARMS) conditions: methodology of a multicentre observational study

INTRODUCTION

Language is usually considered the social vehicle of thought in intersubjective communications. However, the relationship between language and high-order cognition seems to evade this canonical and unidirectional description (ie, the notion of language as a simple means of thought communication). In recent years, clinical high at-risk mental state (CHARMS) criteria (evolved from the Ultra-High-Risk paradigm) and the introduction of the Clinical Staging system have been proposed to address the dynamicity of early psychopathology. At the same time, natural language processing (NLP) techniques have greatly evolved and have been successfully applied to investigate different neuropsychiatric conditions. The combination of at-risk mental state paradigm, clinical staging system and automated NLP methods, the latter applied on spoken language transcripts, could represent a useful and convenient approach to the problem of early psychopathological distress within a transdiagnostic risk paradigm.

METHODS AND ANALYSIS

Help-seeking young people presenting psychological distress (CHARMS+/- and Clinical Stage 1a or 1b; target sample size for both groups n=90) will be assessed through several psychometric tools and multiple speech analyses during an observational period of 1-year, in the context of an Italian multicentric study. Subjects will be enrolled in different contexts: Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), Section of Psychiatry, University of Genoa-IRCCS Ospedale Policlinico San Martino, Genoa, Italy; Mental Health Department-territorial mental services (ASL 3-Genoa), Genoa, Italy; and Mental Health Department-territorial mental services (AUSL-Piacenza), Piacenza, Italy. The conversion rate to full-blown psychopathology (CS 2) will be evaluated over 2 years of clinical observation, to further confirm the predictive and discriminative value of CHARMS criteria and to verify the possibility of enriching them with several linguistic features, derived from a fine-grained automated linguistic analysis of speech.

ETHICS AND DISSEMINATION

The methodology described in this study adheres to ethical principles as formulated in the Declaration of Helsinki and is compatible with International Conference on Harmonization (ICH)-good clinical practice. The research protocol was reviewed and approved by two different ethics committees (CER Liguria approval code: 591/2020-id.10993; Comitato Etico dell'Area Vasta Emilia Nord approval code: 2022/0071963). Participants will provide their written informed consent prior to study enrolment and parental consent will be needed in the case of participants aged less than 18 years old. Experimental results will be carefully shared through publication in peer-reviewed journals, to ensure proper data reproducibility.

TRIAL REGISTRATION NUMBER

DOI:10.17605/OSF.IO/BQZTN.

Patients' perceptions of self-administered dosing to opioid agonist treatment and other changes during the COVID-19 pandemic: a qualitative study

OBJECTIVES

During the COVID-19 pandemic, addiction treatment services received official guidance asking them to limit face-to-face contact with patients and to prescribe opioid agonist treatment (OAT) medication flexibly. With the aim for most patients to receive take-home supplies for self-administration rather than attendance for observed daily dosing.

DESIGN

This was a theory-driven, clinically applied qualitative study, with data for thematic analysis collected by semi-structured, audio-recorded, telephone interviews.

PARTICIPANTS

Twenty-seven adults (aged ≥18 years) enrolled in sublingual (tablet) buprenorphine and oral (liquid) methadone OAT.

SETTING

Community addictions centre in the London Borough of Lambeth operated by South London and Maudsley NHS Trust.

RESULTS

Three major themes were identified: (1) dissatisfaction and perceived stigma with OAT medication dispensing arrangements before the pandemic; (2) positive adaptations in response to COVID-19 by services; (3) participants recommended that, according to preference and evidence of adherence, OAT should be personalised to offer increasing medication supplies for self-administration from as early as 7 days after commencement of maintenance prescribing.

CONCLUSIONS

In an applied qualitative study of patients enrolled in OAT during the COVID-19 pandemic, participants endorsed their opportunity to take medication themselves at home and with virtual addiction support. Most patients described a preference for self-administration with increased dispensing supplies, from as early as 7 days into maintenance treatment, if they could demonstrate adherence to their prescription.

Effectiveness of a targeted brief intervention for recent suicide attempt survivors: a randomised controlled trial protocol

INTRODUCTION

Effective, brief, low-cost interventions for suicide attempt survivors are essential to saving lives and achieving the goals of the National Strategy for Suicide Prevention and Zero Suicide. This study aims to examine the effectiveness of the Attempted Suicide Short Intervention Program (ASSIP) in averting suicide reattempts in the United States healthcare system, its psychological mechanisms as predicted by the Interpersonal Theory of Suicide, and the potential implementation costs, barriers and facilitators for delivering it.

METHODS AND ANALYSIS

This study is a hybrid type 1 effectiveness-implementation randomised controlled trial (RCT). ASSIP is delivered at three outpatient mental healthcare clinics in New York State. Participant referral sites include three local hospitals with inpatient and comprehensive psychiatric emergency services, and outpatient mental health clinics. Participants include 400 adults who have had a recent suicide attempt. All are randomised to 'Zero Suicide-Usual Care plus ASSIP' or 'Zero Suicide-Usual Care'. Randomisation is stratified by sex and whether the index attempt is a first suicide attempt or not. Participants complete assessments at baseline, 6 weeks, and 3, 6, 12 and, 18 months. The primary outcome is the time from randomisation to the first suicide reattempt. Prior to the RCT, a 23-person open trial took place, in which 13 participants received 'Zero Suicide-Usual Care plus ASSIP' and 14 completed the first follow-up time point.

ETHICS AND DISSEMINATION

This study is overseen by the University of Rochester, with single Institutional Review Board (#3353) reliance agreements from Nathan Kline Institute (#1561697) and SUNY Upstate Medical University (#1647538). It has an established Data and Safety Monitoring Board. Results will be published in peer-reviewed academic journals, presented at scientific conferences, and communicated to referral organisations. Clinics considering ASSIP may use a stakeholder report generated by this study, including incremental cost-effectiveness data from the provider point of view.

TRIAL REGISTRATION NUMBER

NCT03894462.

Four 2×2 factorial trials of smartphone CBT to reduce subthreshold depression and to prevent new depressive episodes among adults in the community-RESiLIENT trial (Resilience Enhancement with Smartphone in LIving ENvironmenTs): a master protocol

INTRODUCTION

The health burden due to depression is ever increasing in the world. Prevention is a key to reducing this burden. Guided internet cognitive-behavioural therapies (iCBT) appear promising but there is room for improvement because we do not yet know which of various iCBT skills are more efficacious than others, and for whom. In addition, there has been no platform for iCBT that can accommodate ongoing evolution of internet technologies.

METHODS AND ANALYSIS

Based on our decade-long experiences in developing smartphone CBT apps and examining them in randomised controlled trials, we have developed the Resilience Training App Version 2. This app now covers five CBT skills: cognitive restructuring, behavioural activation, problem-solving, assertion training and behaviour therapy for insomnia. The current study is designed as a master protocol including four 2×2 factorial trials using this app (1) to elucidate specific efficacies of each CBT skill, (2) to identify participants' characteristics that enable matching between skills and individuals, and (3) to allow future inclusion of new skills. We will recruit 3520 participants with subthreshold depression and ca 1700 participants without subthreshold depression, to examine the short-term efficacies of CBT skills to reduce depressive symptoms in the former and to explore the long-term efficacies in preventing depression in the total sample. The primary outcome for the short-term efficacies is the change in depressive symptoms as measured with the Patient Health Questionnaire-9 at week 6, and that for the long-term efficacies is the incidence of major depressive episodes as assessed by the computerised Composite International Diagnostic Interview by week 50.

ETHICS AND DISSEMINATION

The trial has been approved by the Ethics Committee of Kyoto University Graduate School of Medicine (C1556).

TRIAL REGISTRATION NUMBER

UMIN000047124.

Comprehensive Geriatric Assessment for younger outpatients with severe mental illness: protocol for a feasibility study

INTRODUCTION

Individuals with severe mental illness are at risk of becoming prematurely frail. There is a critical unmet need for an intervention that reduces the risk of frailty and minimises the associated negative outcomes in this population. This study aims to provide novel evidence on the feasibility, acceptability and preliminary effectiveness of Comprehensive Geriatric Assessment (CGA) to improve health outcomes among people with co-occurring frailty and severe mental illness.

METHODS AND ANALYSIS

Twenty-five participants with frailty and severe mental illness, aged 18-64 years, will be recruited from Metro South Addiction and Mental Health Service outpatient clinics and provided with the CGA. Primary outcome measures will include the feasibility and acceptability of the CGA embedded in routine healthcare. Other variables of interest will include frailty status, quality of life, polypharmacy, and a range of mental and physical health factors.

ETHICS AND DISSEMINATION

All procedures involving human subjects/patients were approved by Metro South Human Research Ethics Committee (HREC/2022/QMS/82272). Study findings will be disseminated through peer-reviewed publications and conference presentations.

Cognitive bias modification for interpretation (CBM-I) for post-traumatic stress disorder: study protocol of an app-based randomised controlled trial

INTRODUCTION

Previous studies indicate that computerised trainings implementing cognitive bias modification (CBM) for interpretation bias might be promising treatments for trauma-related cognitive distortions and symptoms. However, results are mixed, which might be related to the implemented task (sentence completion task), setting, or training duration. Within the present study, we aim to evaluate the efficacy and safety of an app-based intervention for interpretation bias using standardised imagery audio scripts, which is designed as a standalone treatment.

METHODS AND ANALYSIS

The study is a randomised controlled trial, implementing two parallel arms. 130 patients diagnosed with post-traumatic stress disorder (PTSD) will be allocated to either the intervention group or the waiting-list control group receiving treatment as usual. The intervention consists of 3 weeks of an app-based CBM training for interpretation bias using mental imagery, with three training sessions (20 min) per week. Two months after the last training session, 1 week of booster CBM treatment will be implemented, consisting of three additional training sessions. Outcome assessments will be conducted pretraining, 1 week post-training, 2 months post-training, as well as 1 week after the booster session (approximately 2.5 months after initial training termination). The primary outcome is interpretation bias. Secondary outcomes include PTSD-related cognitive distortions and symptom severity, as well as negative affectivity. Outcome assessment will be conducted by intention-to-treat analysis, as well as per-protocol analysis using linear mixed models.

ETHICS AND DISSEMINATION

The study was approved by the Ethics Committee of the State Chamber of Physicians in Baden-Wuerttemberg, Germany (number of approval: F-2022-080). Scientific findings will be published in peer-reviewed journals informing future clinical studies, which focus on the reduction of PTSD-related symptoms using CBM.

TRIAL REGISTRATION NUMBER

German Clinical Trials Register (DRKS00030285; https://drks.de/search/de/trial/DRKS00030285).

Design, development and randomised controlled trial protocol of a smartphone-delivered version of 'SOLAR' for emergency service workers to manage stress and trauma

IntroductionEmergency service workers are routinely exposed to stress and trauma, and there is a need to address mental health symptoms early to prevent chronic impairment and/or psychiatric disorder. Digital health innovations mean that face-to-face psychosocial interventions can now be delivered remotely, which is particularly appealing to populations who have strong preferences for digital delivery, such as emergency service workers. This two phase study aims to first adapt the Skills fOr Life Adjustment and Resilience (SOLAR) programme into a smartphone application ('app'), and then evaluate the effectiveness of this new app.

METHODS AND ANALYSES

First, focus groups and codesign activities with mental health professionals and emergency service workers will be conducted to develop and test the prototype smartphone version of SOLAR (ie, SOLAR-m). Second, a multicentre randomised controlled trial will investigate the effectiveness of the new app, compared with an active control app, in reducing symptoms of anxiety and depression (primary outcome), as well as other indicators of mental health and work performance. Firefighters from one of the largest urban fire and rescue services in Australia who are currently experiencing distress will be invited to participate. After screening and baseline assessment, 240 will be randomised to receive either SOLAR-m or the control app for 5 weeks, with measurements pre, post and 3-month follow-up. Analyses will be conducted within an intention-to-treat framework using mixed modelling.

ETHICS AND DISSEMINATION

The current trial has received ethics approval from the University of Melbourne Human Research Ethics Committee (2021-20632-18826-5). Study results will be disseminated through peer-reviewed journals and conferences, with a focus on how to expand the new app to other trauma-affected populations if proven effective.

TRIAL REGISTRATION NUMBER

ANZCTRN12621001141831.

An investigation of SMART Recovery: protocol for a longitudinal cohort study of individuals making a new recovery attempt from alcohol use disorder

INTRODUCTION

Alcohol use disorder (AUD) remains one of the most pervasive of all psychiatric illnesses conferring a massive health and economic burden. In addition to professional treatments to address AUD, mutual-help organisations such as Alcoholics Anonymous (AA) and newer entities like Self-Management and Recovery Training (SMART Recovery) play increasingly important roles in many societies. While much is known about the positive effects of AA, very little is known about SMART. Hence, this study seeks to estimate real-world patterns of utilisation and benefit from SMART Recovery as well as explore for whom (moderators) and how (mechanisms) SMART confers recovery benefits.

METHODS AND ANALYSIS

Naturalistic, longitudinal, cohort study (n=368) of individuals with AUD recruited between February 2019 and February 2022, initiating a new recovery attempt who self-select into one of four groups at study entry: (1) SMART Recovery; (2) AA; (3) SMART+AA; (4) Neither SMART nor AA; (stratified by Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM 5) severity markers), with assessments conducted at intake, and 3 months, 6 months, 9 months, 12 months, 18 months and 24 months. Primary outcomes are: frequency of SMART and AA meetings attendance; per cent days abstinent and per cent days heavy drinking. Secondary outcomes include psychiatric distress; quality of life and functioning. Moderator variables include sex/gender; race/ethnicity; spirituality. Mediational variables include social networks; coping skills; self-efficacy; impulsivity. Multivariable regression with propensity score matching will test for patterns of attendance and effects of participation over time on outcomes and test for mechanisms and moderators.

ETHICS AND DISSEMINATION

This study involves human participants and was approved by the Massachusetts General Hospital Institutional Review Board (Protocol #: 2017P002029/PHS). Results will be published in peer-reviewed journals and presented at conferences.

REGISTRATION

This is a non-randomised, naturalistic, longitudinal, cohort study, and thus was not registered in advance. Results, therefore, should be considered exploratory.

metaumbrella: the first comprehensive suite to perform data analysis in umbrella reviews with stratification of the evidence

OBJECTIVE

Umbrella reviews are a new form of literature review that summarises the strength and/or quality of the evidence from all systematic reviews and meta-analyses conducted on a broad topic. This type of review thus provides an exhaustive examination of a vast body of information, providing the highest synthesis of knowledge. A critical strength of umbrella reviews is recalculating the meta-analytic estimates within a uniform framework to allow a consistent evidence stratification. To our best knowledge, there is no comprehensive package or software to conduct umbrella reviews.

METHODS

The R package metaumbrella accomplishes this aim by building on three core functions that (1) automatically perform all required calculations in an umbrella review (including but not limited to pairwise meta-analyses), (2) stratify evidence according to various classification criteria and (3) generate a visual representation of the results. In addition, this package allows flexible inputs for each review or meta-analysis analysed (eg, means plus SD, or effect size estimate and CI) and customisation (eg, stratification criteria following Ioannidis, algorithmic GRADE or personalised classification).

RESULTS

The R package metaumbrella thus provides the first comprehensive range of facilities to perform umbrella reviews with stratification of the evidence.

CONCLUSION

To facilitate the use of this package, even for researchers unfamiliar with R, we also provide a JAMOVI module and an open-access, browser-based graphical interface that allow use of the core functions of the package with a few mouse clicks.

Symptom-specific effects of counselling for depression compared to cognitive-behavioural therapy

BACKGROUND

Cognitive-behavioural therapy (CBT) and counselling for depression (CfD) are recommended first-line treatments for depression. While they approach change differently, there is little understanding of the impact those approaches have on change during treatment.

OBJECTIVES

This study aimed to identify whether CBT and CfD target different symptoms and explore the implications of modelling choices when quantifying change during treatment.

METHODS

Symptom-specific effects of treatment were identified using moderated network modelling. This was a retrospective cohort study of 12 756 individuals who received CBT or CfD for depression in primary/community care psychological therapy services in England. Change was modelled several ways within the whole sample and a propensity score matched sample (n=3446).

FINDINGS

CBT for depression directly affected excessive worry, trouble relaxing and apprehensive expectation and had a stronger influence on changes between suicidal ideation and concentration. CfD had a stronger direct influence on thoughts of being a failure and on the associated change between being an easily annoyed and apprehensive of expectation. There were inconsistencies when modelling change using the first and second appointments as the baseline. Residual score models produced more conservative findings than models using difference scores.

CONCLUSIONS

CfD and CBT for depression have differential effects on symptoms demonstrating specific mechanisms of change.

CLINICAL IMPLICATIONS

CBT was uniquely associated with changes in symptoms associated with anxiety and may be better suited to those with anxiety symptoms comorbid to their depression. When assessing change, the baseline should be the first therapy session, not the pretreatment assessment. Residual change scores should be preferred over difference score methods.

Examining the Lancet Commission risk factors for dementia using Mendelian randomisation

BACKGROUND

Dementia incidence is increasing across the globe and currently there are no disease-modifying pharmaceutical treatments. The Lancet Commission on dementia identified 12 modifiable risk factors which explain 40% of dementia incidence. However, whether these associations are causal in nature is unclear.

OBJECTIVE

To examine the modifiable risk factors for dementia as identified in the Lancet Commission review using Mendelian randomisation (MR) to establish if, based on genetic evidence, these associations with different dementia subtypes are causal in nature.

METHODS

Publicly available genome-wide association study data were used for 10 risk factors and Alzheimer's disease (AD), frontotemporal dementia and dementia with Lewy bodies. Two-sample MR using the inverse varianceweighted method was conducted to test for causal relationships. Weighted median MR and MR-Egger were used to test for pleiotropic effects.

RESULTS

Genetic proxied risk for higher levels of smoking (OR: 0.80 (95% CI: 0.69; 0.92), p=0.002), obesity (OR: 0.87 (95% CI: 0.82; 0.92), p<0.001) and blood pressure (OR: 0.90 (95% CI: 0.82; 0.99), p=0.035) appeared to be protective against the risk of AD. Post hoc analyses indicated these associations had pleiotropic effects with the risk of coronary artery disease. Genetic proxied risk of educational attainment was found to be inconsistently associated with the risk of AD.

CONCLUSIONS AND IMPLICATIONS

Post hoc analysis indicated that the apparent protective effects of smoking, obesity and blood pressure were a result of survivor bias. The findings from this study did not support those presented by the Lancet Commission. Evidence from causal inference studies should be considered alongside evidence from epidemiological studies and incorporated into reviews of the literature.