Development of guidelines for caregivers of people with bipolar disorder: a Delphi expert consensus study

Transition to adulthood of adolescents with profound intellectual and multiple disabilities: Content validation of the SGU-PIMD to support families

BACKGROUND

For families with adolescent children, the transition to adulthood is usually challenging. This period may be extra demanding for families with a child with profound intellectual and multiple disabilities due to the child's strong and persistent support needs. To support these families during this phase and to facilitate the transition process of these adolescents, we adapted the Canadian skills for growing up (SGU) into the skills for growing up-profound intellectual and multiple disabilities (SGU-PIMD). The aim of this study is to determine its content validity.

METHOD

A Delphi study with family members and healthcare professionals was conducted.

RESULTS

Results showed good content validity. However, the Delphi panel suggested minor adjustments to improve relevance, comprehensibility and comprehensiveness.

CONCLUSIONS

The current SGU-PIMD can be used in practice for supporting adolescents with profound intellectual and multiple disabilities. However, there are also recommendations for research into the feasibility and acceptability of the instrument.

Towards criteria and symptoms of constipation in people with severe or profound intellectual and multiple disabilities: A Delphi study

Background

Chronic constipation is common in people with intellectual disabilities, and seems to be highly prevalent in people with severe or profound intellectual and multiple disabilities (SPIMD). However, there is no current widely accepted definition for the constipation experienced by these individuals.

Aim

This Delphi study aims to compile a list of operationalized criteria and symptoms of constipation in people with SPIMD based on practical experiences of and consensus between experts supporting them.

Methods

A two-round Delphi study with an intermediate evaluation and analyses was conducted. Parents and relatives of persons with SPIMD and support professionals were included. The panel answered statements and open questions about symptoms and criteria of constipation. They were also requested to provide their opinion about classifying criteria and symptoms into domains. Answers to statements were analysed separately after both rounds with regard to consensus rate and displayed qualitatively; answers to open questions were analysed deductively.

Results

In the first Delphi round (n = 47), consensus was achieved on criteria within the domains 'Defecation' and 'Physical features', that were assigned to broader categories. Symptoms retrieved within the domain 'Behavioural/Emotional' were brought back to the panel as statements. After the second Delphi round (n = 38), consensus was reached on questions about domains, and for eight criteria (domain 'Defecation' n = 5; domain 'Physical features n = 3). Within the domain 'Behavioural/Emotional', consensus was achieved for five symptoms. Criteria and symptoms with consensus >70% were considered 'generic' and <70% as 'personal'. Symptoms mentioned in the text boxes were used to operationalize categories.

Discussion and conclusion

It was possible to compile a list of generic criteria related to the domains 'Defecation' (n = 5) and 'Physical features' (n = 3) supplemented with generic symptoms related to the domain 'Behavioural/Emotional' (n = 5). We propose using both generic as well as personal criteria and symptoms resulting in a personal profile for an individual with SPIMD. Based on the current results, we recommend follow-up research to develop a screening tool to be used by relatives and professional caregivers, and a definition of constipation. This may support reciprocal collaboration and lead to timely identification of constipation in people with SPIMD.

Lexicon for adrenal terms at CT and MRI: a consensus of the Society of Abdominal Radiology adrenal neoplasm disease-focused panel

PURPOSE

Substantial variation in imaging terms used to describe the adrenal gland and adrenal findings leads to ambiguity and uncertainty in radiology reports and subsequently their understanding by referring clinicians. The purpose of this study was to develop a standardized lexicon to describe adrenal imaging findings at CT and MRI.

METHODS

Fourteen members of the Society of Abdominal Radiology adrenal neoplasm disease-focused panel (SAR-DFP) including one endocrine surgeon participated to develop an adrenal lexicon using a modified Delphi process to reach consensus. Five radiologists prepared a preliminary list of 35 imaging terms that was sent to the full group as an online survey (19 general imaging terms, 9 specific to CT, and 7 specific to MRI). In the first round, members voted on terms to be included and proposed definitions; subsequent two rounds were used to achieve consensus on definitions (defined as ≥ 80% agreement).

RESULTS

Consensus for inclusion was reached on 33/35 terms with two terms excluded (anterior limb and normal adrenal size measurements). Greater than 80% consensus was reached on the definitions for 15 terms following the first round, with subsequent consensus achieved for the definitions of the remaining 18 terms following two additional rounds. No included term had remaining disagreement.

CONCLUSION

Expert consensus produced a standardized lexicon for reporting adrenal findings at CT and MRI. The use of this consensus lexicon should improve radiology report clarity, standardize clinical and research terminology, and reduce uncertainty for referring providers when adrenal findings are present.

The lived experience of caring for someone with bipolar disorder: A qualitative study

Being a close family or friend of someone with bipolar disorder (BD) can lead to experiences of increased stress, anxiety and depressive symptoms related to the burden of caring. However, the lived experience of being a carer for a person with BD has not received significant research attention. This study aimed to gain further insight into the experiences of individuals in an informal caring role for someone with BD and determine what additional information and support these people need to take care of both themselves and the person they are caring for. Fifteen qualitative interviews were carried out with carers discussing their lived experiences with utilising coping strategies and supporting someone with BD. Following the interviews, thematic analysis was used to identify five key themes. These themes were: Separation of the person and the disorder, carer health and coping strategies, unpredictability and variability of symptoms, carer disillusionment and silencing, and story sharing and support needs. Overall, the findings highlighted the need for increased in-person and online support specifically tailored for carers with loved ones experiencing BD.

Patient and public involvement in the development of clinical practice guidelines: a scoping review

OBJECTIVES

Organisations that develop clinical practice guidelines (CPGs) encourage involvement of patients and the publics in their development, however, there are no standard methodologies for doing so. To examine how CPGs report patient and public involvement (PPI), we conducted a scoping review of the evidence addressing the following four questions: (1) who are the patients and publics involved in developing the CPG?; (2) from where and how are the patients and publics recruited?; (3) at what stage in the CPG development process are the patients and publics involved? and (4) how do the patients and publics contribute their views? We also extracted data on the use of PPI reporting checklists by the included studies.

DESIGN

We used the methodology developed by Arksey and O'Malley and refined by the Joanna Briggs Institute. We searched PubMed, Embase, CINAHL and PsycINFO, websites of national guideline bodies from the UK, Canada, Australia and the USA, and conducted a forward citation search. No language, date or participant demographics restrictions were applied. Data were synthesised narratively.

RESULTS

We included 47 studies addressing 1 or more of the 4 questions. All included studies reported who the patient and publics involved (PPI members) were, and several studies reported PPI members from different groups. Patients were reported in 43/47 studies, advocates were reported in 22/47 studies, patients and advocates reported in 17/47 studies, and general public reported in 2/47 studies. Thirty-four studies reported from where the patients and publics were recruited, with patient groups being the most common (20/34). Stage of involvement was reported by 42/47 studies, most commonly at question identification (26/42) and draft review (18/42) stages. Forty-two studies reported how the patients contributed, most commonly via group meetings (18/42) or individual interviews. Ten studies cited or used a reporting checklist to report findings.

CONCLUSIONS

Our scoping review has revealed knowledge gaps to inform future research in several ways: replication, terminology and inclusion. First, no standard approach to PPI in CPG development could be inferred from the research. Second, inconsistent terminology to describe patients and publics reduces clarity around which patients and publics have been involved in developing CPGs. Finally, the under-representation of research describing PPI in the development of screening, as opposed to treatment, CPGs warrants further attention.

Lexicon for renal mass terms at CT and MRI: a consensus of the society of abdominal radiology disease-focused panel on renal cell carcinoma

PURPOSE

There is substantial variation in the radiologic terms used to characterize renal masses, leading to ambiguity and inconsistency in clinical radiology reports and research studies. The purpose of this study was to develop a standardized lexicon to describe renal masses at CT and MRI.

MATERIALS AND METHODS

This multi-institutional, prospective, quality improvement project was exempt from IRB oversight. Thirteen radiologists belonging to the Society of Abdominal Radiology (SAR) disease-focused panel on renal cell carcinoma representing nine academic institutions participated in a modified Delphi process to create a lexicon of terms used to describe imaging features of renal masses at CT and MRI. In the first round, members voted on terms to be included and proposed definitions; subsequent voting rounds and a teleconference established consensus. One non-voting member developed the questionnaire and consolidated responses. Consensus was defined as ≥ 80% agreement.

RESULTS

Of 37 proposed terms, 6 had consensus to be excluded. Consensus for inclusion was reached for 30 of 31 terms (13/14 basic imaging terms, 8/8 CT terms, 6/6 MRI terms and 3/3 miscellaneous terms). Despite substantial initial disagreement about definitions of 'renal mass,' 'necrosis,' 'fat,' and 'restricted diffusion' in the first round, consensus for all was eventually reached. Disagreement remained for the definition of 'solid mass.'

CONCLUSIONS

A modified Delphi method produced a lexicon of preferred terms and definitions to be used in the description of renal masses at CT and MRI. This lexicon should improve clarity and consistency of radiology reports and research related to renal masses.

What parents want to know in the first postnatal year: A Delphi consensus study

BACKGROUND

Early postnatal psychoeducation intervention programmes can support new parents in the adjustment to parenthood. However, most psychoeducation programmes focus on pregnancy and the birth and fail to deliver relevant and age-specific information to new parents about what to expect in the postpartum period. Learning more about this intense period in a new parent's life will facilitate a healthy transition to parenthood. Considering the needs of time-poor but tech-savvy new parents, it is also necessary to rethink the delivery methods of such information to maximize impact.

METHOD

Two panels of experts in perinatal mental health (eight professionals and eight parents with lived experience) participated in a Delphi consensus study to establish what topics of information are most important for parents in the first postnatal year.

RESULTS

A total of 89 topics of information were endorsed by at least 80% of both panels as Essential or Good to Know information for new parents. The topics were grouped under the following themes: sleep, attachment, co-parenting, parental mental health, developmental milestones, feeding, social and community support, safety and health.

CONCLUSIONS

This study established consensus between perinatal experts and parents with lived experience in order to produce relevant m-health psychoeducation for parents in the first postnatal year. The study findings will inform the development of perinatal m-health psychoeducation programmes.

Addressing Delusions in Women and Men with Delusional Disorder: Key Points for Clinical Management

Delusional disorders (DD) are difficult conditions for health professionals to treat successfully. They are also difficult for family members to bear. The aim of this narrative review is to select from the clinical literature the psychosocial interventions that appear to work best for these conditions and to see whether similar strategies can be modeled or taught to family members so that tensions at home are reduced. Because the content of men's and women's delusions sometimes differ, it has been suggested that optimal interventions for the two sexes may also differ. This review explores three areas: (a) specific treatments for men and women; (b) recommended psychological approaches by health professionals, especially in early encounters with patients with DD; and (c) recommended psychoeducation for families. Findings are that there is no evidence for differentiated psychosocial treatment for men and women with delusional disorder. What is recommended in the literature is to empathically elicit the details of the content of delusions, to address the accompanying emotions rather than the logic of the presented argument, to teach self-soothing techniques, and to monitor behavior with respect to its safety. These recommendations have only been validated in individual patients and families. More rigorous clinical trials need to be conducted.

Using a Delphi survey to gain an international consensus on the challenges of conducting trials with adults with intellectual disabilities

BACKGROUND/AIMS

People with intellectual disability experience higher rates of multi-morbidity and health inequalities, they are frequently prescribed medications and more likely to have an avoidable or premature death. There is a recognised lack of randomised controlled trials, and subsequently a lack of evidence base, for many of the interventions and treatments provided to people with intellectual disabilities. Very few disability-specific trials are conducted, and people with intellectual, and other cognitive, disabilities are routinely excluded from mainstream trials. There is an urgent need to facilitate more disability-specific trials or to encourage mainstream trialists to include people with disabilities in their studies. Obtaining a thorough understanding of the challenges inherent in these trials, and sharing this knowledge within the research community, may contribute significantly towards addressing this need. The aim of this study was to explore the practical and methodological challenges to conducting trials with adults with intellectual disabilities and to reach a consensus regarding which are the most important challenges for researchers for inclusion in a resource toolkit.

METHODS

A three-round modified Delphi survey was conducted with a panel of international trials researchers within the intellectual disability field. Items were assessed in terms of the consensus level and stability of responses.

RESULTS

A total of 64 challenges and barriers were agreed upon, across all aspects of the trial pathway, from planning through to reporting. Some challenges and barriers had been noted in the literature previously, but many previously uncited barriers (both systemic and attitudinal) were identified.

CONCLUSION

This is the first international survey exploring the experiences of researchers conducting randomised controlled trials with adults with intellectual disabilities. Many of the barriers and challenges reported can be overcome with creativity and some additional resources. Other challenges, including attitudes towards conducting trials with disabled populations, maybe harder to overcome. These findings have implications for conducting trials with other populations with cognitive or communication difficulties. Implications for disability researchers, funding bodies and ethical review panels are discussed.

A transdiagnostic dimensional approach towards a neuropsychological assessment for addiction: an international Delphi consensus study

BACKGROUND

The US National Institutes of Mental Health Research Domain Criteria (RDoC) seek to stimulate research into biologically validated neuropsychological dimensions across mental illness symptoms and diagnoses. The RDoC framework comprises 39 functional constructs designed to be revised and refined, with the overall goal of improving diagnostic validity and treatments. This study aimed to reach a consensus among experts in the addiction field on the 'primary' RDoC constructs most relevant to substance and behavioural addictions.

METHODS

Forty-four addiction experts were recruited from Australia, Asia, Europe and the Americas. The Delphi technique was used to determine a consensus as to the degree of importance of each construct in understanding the essential dimensions underpinning addictive behaviours. Expert opinions were canvassed online over three rounds (97% completion rate), with each consecutive round offering feedback for experts to review their opinions.

RESULTS

Seven constructs were endorsed by ≥ 80% of experts as 'primary' to the understanding of addictive behaviour: five from the Positive Valence System (reward valuation, expectancy, action selection, reward learning, habit); one from the Cognitive Control System (response selection/inhibition); and one expert-initiated construct (compulsivity). These constructs were rated to be related differentially to stages of the addiction cycle, with some linked more closely to addiction onset and others more to chronicity. Experts agreed that these neuropsychological dimensions apply across a range of addictions.

CONCLUSIONS

The study offers a novel and neuropsychologically informed theoretical framework, as well as a cogent step forward to test transdiagnostic concepts in addiction research, with direct implications for assessment, diagnosis, staging of disorder, and treatment.

Understanding the role of m-health to improve well-being in spouses of patients with bipolar disorder

OBJECTIVES

Spouses and partners of individuals with bipolar disorder (BD) experience significant burden. As there are some limitations to standard psychosocial caregiver interventions, mobile health technology (mHealth) may be a way to reduce burden and improve well-being in these caregivers. The purpose of this study was to explore how the well-being of spouses or partners of patients with BD can be improved through mHealth technology.

METHODS

Using a qualitative design, we conducted five focus groups and one in-depth individual interview to collect information from participants about what they would expect from such a device. The sample consists of thirteen participants (eleven spouses and two partners). The age range was 29-65, with eight females and five males. Data were collected using minimally structured interviews and independently analyzed by the authors using content analysis.

RESULTS

Results indicated that the mHealth device many be helpful in at least six areas: reduction of stressors, decreased social isolation, improving communication in the relationship between the spouses, speaking with children about the illness, managing medications, and providing information on resources.

CONCLUSION

Mobile health technology may be a feasible, available, and cost-effective support tool for spouses and partners of individuals with BD, especially in reducing caregiver stress. Future research is needed to develop the application and test its effectiveness on health outcomes in a larger trial.

Development of a tool for monitoring the prescribing of antipsychotic medications to people with dementia in general practice: a modified eDelphi consensus study

Background

Despite their adverse effects, antipsychotics are frequently used to manage behavioral and psychological symptoms of dementia. Regular monitoring of antipsychotic prescribing has been shown to improve the appropriateness of prescribing. However, there is currently no consensus on what the components of such a monitoring tool would be.

Aim

The aim of this study was to use an expert consensus process to identify the key components of an antipsychotic repeat prescribing tool for use with people with dementia in a general practice setting.

Methods

A modified eDelphi technique was employed. We invited multidisciplinary experts in antipsychotic prescribing to people with dementia to participate. These experts included general practitioners (GPs), geriatricians and old age psychiatrists. The list of statements for round 1 was developed through a review of existing monitoring tools and international best practice guidelines. In the second round of the Delphi, any statement that had not reached consensus in the first round was presented for re-rating, with personalized feedback on the group and the individual’s response to the specific statement. The final round consisted of a face-to-face expert meeting to resolve any uncertainties from round 2.

Results

A total of 23 items were rated over two eDelphi rounds and one face-to-face consensus meeting to yield a total of 18 endorsed items and five rejected items. The endorsed statements informed the development of a structured, repeat prescribing tool for monitoring antipsychotics in people with dementia in primary care.

Conclusion

The development of repeat prescribing tool provides GPs with practical advice that is lacking in current guidelines and will help to support GPs by providing a structured format to use when reviewing antipsychotic prescriptions for people with dementia, ultimately improving patient care. The feasibility and acceptability of the tool now need to be evaluated in clinical practice.

Support Needs for Family Caregivers of Clients with Mental Illness in Iran: A Qualitative Study

This paper explored the support needs of family caregivers of people living with a mental illness in Iran. This descriptive study focused on the experiences of 20 family caregivers as well as the views of 29 professional support workers through individual face-to-face interviews. From these interviews three key themes emerged in regards to the care needs of family caregivers: (i) social support; (ii) emotional support; and (iii) safety and security. These themes highlighted the complex role of caring for a family member with a mental illness and the emotional, social and economic challenges that these caregivers experienced as a result. Iranian caregivers garnered support not only from other family members but also from neighbors and religious leaders but lacked the much needed respite care found in western countries. This research study highlighted the importance of ensuring that the caregivers themselves receive appropriate and adequate support to fulfill their caregiving role.

Discrimination and support from friends and family members experienced by people with mental health problems: findings from an Australian national survey

PURPOSE

To investigate the scope and nature of discrimination and positive treatment experienced by adults with mental health problems from their friends and family in a population-based survey.

METHODS

An Australian telephone-survey of 5220 adults included 1381 individuals who reported a mental health problem or scored high on a screening questionnaire. Respondents were interviewed about their experience of discrimination and positive treatment from their friends, spouse and other family members. Descriptions of experiences were content-analysed to identify key characteristics.

RESULTS

Mental health diagnoses were primarily depression or anxiety disorders, and just over half had received treatment in the last 12 months. Positive treatment from family and friends was far more common than discrimination, reported by 74.1% of respondents. This was primarily characterised by providing emotional support and maintaining contact, as well as checking on their mental health and being a good listener. Nevertheless, discriminatory behaviours from friends and family were reported by 25.8% of respondents, with reducing or cutting contact being by far the most common. Friends and family also commonly dismissed that mental illness was real or caused suffering and showed a lack of understanding about mental health problems or treatments and how they can impact behaviour and functioning.

CONCLUSIONS

This nationally representative study of real life experiences highlights the potential for harm or benefit from a person's social support network. Despite positive experiences being common, there is an ongoing need to reduce mental illness stigma and improve understanding of how to support a loved one with a mental health problem.

Staging in bipolar disorder: from theoretical framework to clinical utility

Illness staging is widely utilized in several medical disciplines to help predict course or prognosis, and optimize treatment. Staging models in psychiatry in general, and bipolar disorder in particular, depend on the premise that psychopathology moves along a predictable path: an at-risk or latency stage, a prodrome progressing to a first clinical threshold episode, and one or more recurrences with the potential to revert or progress to late or end-stage manifestations. The utility and validity of a staging model for bipolar disorder depend on its linking to clinical outcome, treatment response and neurobiological measures. These include progressive biochemical, neuroimaging and cognitive changes, and potentially stage-specific differences in response to pharmacological and psychosocial treatments. Mechanistically, staging models imply the presence of an active disease process that, if not remediated, can lead to neuroprogression, a more malignant disease course and functional deterioration. Biological elements thought to be operative in bipolar disorder include a genetic diathesis, physical and psychic trauma, epigenetic changes, altered neurogenesis and apoptosis, mitochondrial dysfunction, inflammation, and oxidative stress. Many available agents, such as lithium, have effects on these targets. Staging models also suggest the utility of stage-specific treatment approaches that may not only target symptom reduction, but also impede illness neuroprogression. These treatment approaches range from prevention for at-risk individuals, to early intervention strategies for prodromal and newly diagnosed individuals, complex combination therapy for rapidly recurrent illness, and palliative-type approaches for those at chronic, late stages of illness. There is hope that prompt initiation of potentially disease modifying therapies may preclude or attenuate the cognitive and structural changes seen in the later stages of bipolar disorder. The aims of this paper are to: a) explore the current level of evidence supporting the descriptive staging of the syndromal pattern of bipolar disorder; b) describe preliminary attempts at validation; c) make recommendations for the direction of further studies; and d) provide a distillation of the potential clinical implications of staging in bipolar disorder within a broader transdiagnostic framework.

Royal Australian and New Zealand College of Psychiatrists expert consensus statement for the treatment, management and monitoring of the physical health of people with an enduring psychotic illness

OBJECTIVE

To use expert consensus to inform the development of policy and guidelines for the treatment, management and monitoring of the physical health of people with an enduring psychotic illness.

METHOD

The Delphi method was used. A systematic search of websites, books and journal articles was conducted to develop a 416-item survey containing strategies that health professionals should use to treat, manage and monitor the physical health of people with an enduring psychotic illness. Three panels of Australian experts (55 clinicians, 21 carers and 20 consumers) were recruited and independently rated the items over three rounds, with strategies reaching consensus on a priori-defined levels of importance written into the expert consensus statement.

RESULTS

The participation rate for the clinicians across all three rounds was 65%, with consumers and carers only completing one round due to high endorsement rates. Finally, 386 strategies were endorsed as essential or important by one or all panels. The endorsed strategies provided information on engagement and collaborative partnerships; clinical governance; risk factors, morbidity and mortality in people with enduring psychotic illness; assessment, including initial and follow-up assessments; barriers to care; strategies to improve care of people with enduring psychotic illness; education and training; treatment recommendations; medication side effects; and the role of health professionals.

CONCLUSION

The consensus statement is intended to be used by health professionals, people with an enduring psychotic illness and their families and carers. The next step needed is an implementation strategy by the Royal Australian and New Zealand College of Psychiatrists and other stakeholders.

The International College of Neuropsychopharmacology (CINP) Treatment Guidelines for Bipolar Disorder in Adults (CINP-BD-2017), Part 4: Unmet Needs in the Treatment of Bipolar Disorder and Recommendations for Future Research

BACKGROUND

The current fourth paper on the International College of Neuropsychopharmacology guidelines for the treatment of bipolar disorder reports on the unmet needs that became apparent after an extensive review of the literature and also serves as a conclusion to the project of the International College of Neuropsychopharmacology workgroup.

MATERIALS AND METHODS

The systematic review of the literature that was performed to develop the International College of Neuropsychopharmacology guidelines for bipolar disorder identified and classified a number of potential shortcomings.

RESULTS

Problems identified concerned the reliability and validity of the diagnosis of bipolar disorder and especially of bipolar depression. This, in turn, has profound consequences for early detection and correct treatment of the disorder. Another area that needs improvement is the unsatisfactory efficacy and effectiveness of therapeutic options, especially in special populations such as those with mixed features and rapid cycling course. Gender issues and adherence problems constitute an additional challenge. The literature suggests that while treatment providers are concerned more with treatment-related issues, patients and their caregivers worry more about issues pertaining to the availability of services and care, quality of life, and various types of burden. The workgroup identified additional unmet needs related to the current standard of research in bipolar disorder. These include the fragmentation of bipolar disorder into phases that are handled as being almost absolutely independent from each other, and thus the development of an overall therapeutic strategy on the basis of the existing evidence is very difficult. Trials are not always designed in a way that outcomes cover the most important aspects of bipolar disorder, and often the reporting of the results is biased and unsatisfactory. The data on combination treatments and high dosages are sparse, whereas they are common in real world practice.

CONCLUSIONS

The workgroup endorses the full release of raw study data to the scientific community, and the development of uniform clinical trial standards (also including more realistic outcomes) and the reporting of results. The 2 large appendices summarize the results of this systematic review with regard to the areas of lack of knowledge where further focused research is necessary.

Effective self-management strategies for bipolar disorder: A community-engaged Delphi Consensus Consultation study

BACKGROUND

Self-management represents an important complement to psychosocial treatments for bipolar disorder (BD), but research is limited. Specifically, little is known about self-management approaches for elevated mood states; this study investigated self-management strategies for: (1) maintaining balance in mood, and (2) stopping progression into hypomania/mania.

METHODS

To identify the common components of BD self-management, Delphi Consensus Consultation methods were combined with a Community-Based Participatory Research (CBPR) approach across five study phases: (1) Qualitative dataset content analysis; (2) Academic/grey literature reviews; (3) Content analysis; (4) Two Delphi rounds (rating strategies on a 5-point Likert scale, Very Unhelpful-Very Helpful), and; (5) Quantitative analysis and interpretation. Participants were people with BD and healthcare providers.

RESULTS

Phases 1 and 2 identified 262 and 3940 candidate strategies, respectively; 3709 were discarded as duplicates/unintelligible. The remaining 493 were assessed via Delphi methods in Phase 4: 101 people with BD and 52 healthcare providers participated in Round 1; 83 of the BD panel (82%) and 43 of the healthcare provider panel (83%) participated in Round 2-exploratory factor analysis (EFA) was conducted on Round 2 results.

LIMITATIONS

EFA was underpowered and sample was not ethnically diverse, limiting generalizability.

DISCUSSION

High concordance was observed in ratings of strategy effectiveness between the two panels. Future research could usefully investigate the provisional discovery here of underlying factors which link individual strategies. For example, 'maintaining hope' underpinned strategies for maintaining balance, and 'decreasing use of stimulants' underpinned strategies to interrupt hypo/manic ascent. There is merit in combining CBPR and Delphi methods.

Lithiumeter: Version 2.0

BACKGROUND

The Lithiumeter was developed as a visual and practical guide for determining lithium levels in the management of bipolar disorder (BD). It appears to have been well received, as evidenced by its increasing popularity amongst doctors as a deskside clinical aide, and adoption and reproduction of the schematic in clinical guidelines and texts. However, since its publication 5 years ago, key basic neuroscience and clinical research developments pertaining to lithium have significantly advanced our understanding, necessitating further refinement of guidance concerning the practicalities of lithium therapy.

METHODS

Literature concerning the indications for, and therapeutic levels of, lithium and the associated acute and chronic risks of therapy was scrutinized as part of updating clinical practice guidelines. We have reviewed these updates and identified significant areas of change with respect to the previous Lithiumeter (version 1.0).

RESULTS

Since 2011, updated clinical practice guidelines have narrowed the indicated plasma lithium concentration for maintenance therapy, suggesting that additional guidance is necessary for optimizing treatment. Relevant updated clinical guidance was integrated to constitute the Lithiumeter 2.0, which provides a more comprehensive overview of the practical aspects of lithium therapy while maintaining a focus on optimization of lithium levels, such as differential titration of lithium depending on the current mood state.

CONCLUSIONS

The Lithiumeter 2.0 is an update that clinicians will find useful for their practice. By addressing some of the issues faced in clinical practice, translational clinical research will continue to inform the Lithiumeter in future updates.

Enhancing reciprocal partner support to prevent perinatal depression and anxiety: a Delphi consensus study

BACKGROUND

Systematic reviews have established that partner support protects against perinatal mood problems. It is therefore a key target for interventions designed to prevent maternal and paternal depression and anxiety. Nonetheless, the extant literature is yet to be translated into specific actions that parents can implement. Prevention efforts aiming to facilitate reciprocal partner support within the couple dyad need to provide specific guidance on how partners can support one another to reduce their vulnerability to perinatal depression and anxiety.

METHOD

Two panels of experts in perinatal mental health (21 consumer advocates and 39 professionals) participated in a Delphi consensus study to establish how partners can support one another to reduce their risk of developing depression and anxiety during pregnancy and the postpartum period.

RESULTS

A total of 214 recommendations on how partners can support each other were endorsed by at least 80 % of both panels as important or essential in reducing the risk of perinatal depression and anxiety. The recommendations were grouped under the following categories: becoming a parent, supporting each other through pregnancy and childbirth, communication, conflict, division of labor, practical support, emotional support, emotional closeness, sexual satisfaction, using alcohol and drugs, encouraging self-care, developing acceptance, and help-seeking.

CONCLUSION

This study established consensus between consumers and professionals in order to produce a set of guidelines on how partners can support each other to prevent depression and anxiety during pregnancy and following childbirth. It is hoped that these guidelines will inform the development of perinatal depression and anxiety prevention efforts.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders

OBJECTIVES

To provide guidance for the management of mood disorders, based on scientific evidence supplemented by expert clinical consensus and formulate recommendations to maximise clinical salience and utility.

METHODS

Articles and information sourced from search engines including PubMed and EMBASE, MEDLINE, PsycINFO and Google Scholar were supplemented by literature known to the mood disorders committee (MDC) (e.g., books, book chapters and government reports) and from published depression and bipolar disorder guidelines. Information was reviewed and discussed by members of the MDC and findings were then formulated into consensus-based recommendations and clinical guidance. The guidelines were subjected to rigorous successive consultation and external review involving: expert and clinical advisors, the public, key stakeholders, professional bodies and specialist groups with interest in mood disorders.

RESULTS

The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders (Mood Disorders CPG) provide up-to-date guidance and advice regarding the management of mood disorders that is informed by evidence and clinical experience. The Mood Disorders CPG is intended for clinical use by psychiatrists, psychologists, physicians and others with an interest in mental health care.

CONCLUSIONS

The Mood Disorder CPG is the first Clinical Practice Guideline to address both depressive and bipolar disorders. It provides up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus.

MOOD DISORDERS COMMITTEE

Professor Gin Malhi (Chair), Professor Darryl Bassett, Professor Philip Boyce, Professor Richard Bryant, Professor Paul Fitzgerald, Dr Kristina Fritz, Professor Malcolm Hopwood, Dr Bill Lyndon, Professor Roger Mulder, Professor Greg Murray, Professor Richard Porter and Associate Professor Ajeet Singh.

INTERNATIONAL EXPERT ADVISORS

Professor Carlo Altamura, Dr Francesco Colom, Professor Mark George, Professor Guy Goodwin, Professor Roger McIntyre, Dr Roger Ng, Professor John O'Brien, Professor Harold Sackeim, Professor Jan Scott, Dr Nobuhiro Sugiyama, Professor Eduard Vieta, Professor Lakshmi Yatham.

AUSTRALIAN AND NEW ZEALAND EXPERT ADVISORS

Professor Marie-Paule Austin, Professor Michael Berk, Dr Yulisha Byrow, Professor Helen Christensen, Dr Nick De Felice, A/Professor Seetal Dodd, A/Professor Megan Galbally, Dr Josh Geffen, Professor Philip Hazell, A/Professor David Horgan, A/Professor Felice Jacka, Professor Gordon Johnson, Professor Anthony Jorm, Dr Jon-Paul Khoo, Professor Jayashri Kulkarni, Dr Cameron Lacey, Dr Noeline Latt, Professor Florence Levy, A/Professor Andrew Lewis, Professor Colleen Loo, Dr Thomas Mayze, Dr Linton Meagher, Professor Philip Mitchell, Professor Daniel O'Connor, Dr Nick O'Connor, Dr Tim Outhred, Dr Mark Rowe, Dr Narelle Shadbolt, Dr Martien Snellen, Professor John Tiller, Dr Bill Watkins, Dr Raymond Wu.

Using the Delphi expert consensus method in mental health research

OBJECTIVE

The article gives an introductory overview of the use of the Delphi expert consensus method in mental health research. It explains the rationale for using the method, examines the range of uses to which it has been put in mental health research, and describes the stages of carrying out a Delphi study using examples from the literature.

METHOD

To ascertain the range of uses, a systematic search was carried out in PubMed. The article also examines the implications of 'wisdom of crowds' research for how to conduct Delphi studies.

RESULTS

The Delphi method is a systematic way of determining expert consensus that is useful for answering questions that are not amenable to experimental and epidemiological methods. The validity of the approach is supported by 'wisdom of crowds' research showing that groups can make good judgements under certain conditions. In mental health research, the Delphi method has been used for making estimations where there is incomplete evidence (e.g. What is the global prevalence of dementia?), making predictions (e.g. What types of interactions with a person who is suicidal will reduce their chance of suicide?), determining collective values (e.g. What areas of research should be given greatest priority?) and defining foundational concepts (e.g. How should we define 'relapse'?). A range of experts have been used in Delphi research, including clinicians, researchers, consumers and caregivers.

CONCLUSION

The Delphi method has a wide range of potential uses in mental health research.

Gadamerian philosophical hermeneutics as a useful methodological framework for the Delphi technique

In this article we aim to demonstrate how Gadamerian philosophical hermeneutics may provide a sound methodological framework for researchers using the Delphi Technique (Delphi) in studies exploring health and well-being. Reporting of the use of Delphi in health and well-being research is increasing, but less attention has been given to covering its methodological underpinnings. In Delphi, a structured anonymous conversation between participants is facilitated, via an iterative survey process. Participants are specifically selected for their knowledge and experience with the topic of interest. The purpose of structuring conversation in this manner is to cultivate collective opinion and highlight areas of disagreement, using a process that minimizes the influence of group dynamics. The underlying premise is that the opinion of a collective is more useful than that of an individual. In designing our study into health literacy, Delphi aligned well with our research focus and would enable us to capture collective views. However, we were interested in the methodology that would inform our study. As researchers, we believe that methodology provides the framework and principles for a study and is integral to research integrity. In assessing the suitability of Delphi for our research purpose, we found little information about underpinning methodology. The absence of a universally recognized or consistent methodology associated with Delphi was highlighted through a scoping review we undertook to assist us in our methodological thinking. This led us to consider alternative methodologies, which might be congruent with the key principles of Delphi. We identified Gadamerian philosophical hermeneutics as a methodology that could provide a supportive framework and principles. We suggest that this methodology may be useful in health and well-being studies utilizing the Delphi method.

Challenges in measuring outcomes for caregivers of people with mental health problems

Patient-reported outcomes (PROs) are increasingly important in health care and mental health research. Furthermore, caregivers become partners in care for patients with mental disorders, and health workers are more attentive to the expectations and needs of caregivers. A number of outcomes for caregivers are measured and used in daily practice in order to promote actions to improve health care systems and progress in research on the impact of mental disorders on their caregivers. This paper proposes an inventory of the different outcomes and different measurement tools used to assess the impact of disorders, raising a number of methodological and conceptual issues that limit the relevance of measurement tools and complicate their use. Finally, we propose some recommendations promoting the development of relevant outcome measures for caregivers and their integration into current systems of care.

Molecular strategies for targeting antioxidants to mitochondria: therapeutic implications

Mitochondrial function and specifically its implication in cellular redox/oxidative balance is fundamental in controlling the life and death of cells, and has been implicated in a wide range of human pathologies. In this context, mitochondrial therapeutics, particularly those involving mitochondria-targeted antioxidants, have attracted increasing interest as potentially effective therapies for several human diseases. For the past 10 years, great progress has been made in the development and functional testing of molecules that specifically target mitochondria, and there has been special focus on compounds with antioxidant properties. In this review, we will discuss several such strategies, including molecules conjugated with lipophilic cations (e.g., triphenylphosphonium) or rhodamine, conjugates of plant alkaloids, amino-acid- and peptide-based compounds, and liposomes. This area has several major challenges that need to be confronted. Apart from antioxidants and other redox active molecules, current research aims at developing compounds that are capable of modulating other mitochondria-controlled processes, such as apoptosis and autophagy. Multiple chemically different molecular strategies have been developed as delivery tools that offer broad opportunities for mitochondrial manipulation. Additional studies, and particularly in vivo approaches under physiologically relevant conditions, are necessary to confirm the clinical usefulness of these molecules.

Development and validation of a question prompt list for parents of children with attention-deficit/hyperactivity disorder: a Delphi study

OBJECTIVES

Question prompt lists (QPLs) are structured lists of disease and treatment-specific questions intended to encourage patient question-asking during consultations with clinicians. The aim of this study was to develop a QPL intended for use by parents of children affected by attention-deficit/hyperactivity disorder (ADHD).

METHODS

The QPL content (111 questions) was derived through thematic analysis of existing ADHD- and QPL-related resources. A modified Delphi method, involving a three-round web-based survey, was used to reach consensus about the QPL content. Thirty-six experts were recruited into either a professional [paediatricians, child and adolescent psychiatrists, psychologists, researchers (n =28)] or non-professional panel [parents of children diagnosed with ADHD, ADHD consumer advocates (n = 8)]. Panel members were asked to rate the importance of the QPL content using a five-point scale ranging from 'Essential' to 'Should not be included'.

RESULTS

A total of 122 questions, including 11 new questions suggested by panellists, were rated by both panels. Of these, 88 (72%) were accepted for inclusion in the QPL. Of the accepted questions, 39 were re-rated during two follow-up survey rounds and 29 (74%) were subsequently accepted for inclusion. The questions covered key topics including diagnosis, understanding ADHD, treatment, health-care team, monitoring ADHD, managing ADHD, future expectations and support and information.

CONCLUSIONS

To our knowledge, this is the first ADHD-specific QPL to be developed and the first use of the Delphi method to validate the content of any QPL. It is anticipated that the QPL will assist parents in obtaining relevant, reliable information and empowering their treatment decisions by enhancing the potential for shared decision making with clinicians.

Stage managing bipolar disorder

OBJECTIVES

Clinical staging is widespread in medicine - it informs prognosis, clinical course, and treatment, and assists individualized care. Staging places an individual on a probabilistic continuum of increasing potential disease severity, ranging from clinically at-risk or latency stage through first threshold episode of illness or recurrence, and, finally, to late or end-stage disease. The aim of the present paper was to examine and update the evidence regarding staging in bipolar disorder, and how this might inform targeted and individualized intervention approaches.

METHODS

We provide a narrative review of the relevant information.

RESULTS

In bipolar disorder, the validity of staging is informed by a range of findings that accompany illness progression, including neuroimaging data suggesting incremental volume loss, cognitive changes, and a declining likelihood of response to pharmacological and psychosocial treatments. Staging informs the adoption of a number of approaches, including the active promotion of both indicated prevention for at-risk individuals and early intervention strategies for newly diagnosed individuals, and the tailored implementation of treatments according to the stage of illness.

CONCLUSIONS

The nature of bipolar disorder implies the presence of an active process of neuroprogression that is considered to be at least partly mediated by inflammation, oxidative stress, apoptosis, and changes in neurogenesis. It further supports the concept of neuroprotection, in that a diversity of agents have putative effects against these molecular targets. Clinically, staging suggests that the at-risk state or first episode is a period that requires particularly active and broad-based treatment, consistent with the hope that the temporal trajectory of the illness can be altered. Prompt treatment may be potentially neuroprotective and attenuate the neurostructural and neurocognitive changes that emerge with chronicity. Staging highlights the need for interventions at a service delivery level and implementing treatments at the earliest stage of illness possible.

Mental Health First Aid is an effective public health intervention for improving knowledge, attitudes, and behaviour: a meta-analysis

Mental Health First Aid (MHFA) is a standardized, psychoeducational programme developed to empower the public to approach, support and refer individuals in distress by improving course participants' knowledge, attitudes and behaviours related to mental ill-health. The present paper aims to synthesize published evaluations of the MHFA programme in a meta-analysis to estimate its effects and potential as a public mental health awareness-increasing strategy. Fifteen relevant papers were identified through a systematic literature search. Standardized effect sizes were calculated for three different outcome measures: change in knowledge, attitudes, and helping behaviours. The results of the meta-analysis for these outcomes yielded a mean effect size of Glass's Δ = 0.56 (95% CI = 0.38 - 0.74; p < 0.001), 0.28 (95% CI = 0.22 - 0.35; p < 0.001) and 0.25 (95% CI = 0.12 - 0.38; p < 0.001), respectively. Results were homogenous, and moderator analyses suggested no systematic bias or differences in results related to study design (with or without control group) or 'publication quality' (journal impact factor). The results demonstrate that MHFA increases participants' knowledge regarding mental health, decreases their negative attitudes, and increases supportive behaviours toward individuals with mental health problems. The MHFA programme appears recommendable for public health action.

Evaluation of the acceptability and usefulness of an information website for caregivers of people with bipolar disorder

BACKGROUND

Bipolar disorder is associated with extreme mood symptoms, disability and suicide risk. Close family or friends often have a primary role in supporting an adult with bipolar disorder. However, not all support is helpful and there is little publicly accessible evidence-based information to guide caregivers. Caregiver burden increases the risk of caregiver depression and health problems. To help fill the information gap, expert clinicians, caregivers and consumers contributed to the development of guidelines for caregivers of adults with bipolar disorder using the Delphi consensus method. This paper reports on an evaluation of the acceptability and usefulness of the online version of the guidelines, http://www.bipolarcaregivers.org.

METHODS

Visitors to the website responded to an initial online survey about the usefulness of the information (N=536). A more detailed follow-up feedback survey was emailed to web users who were adult caregivers of adults with bipolar disorder a month later (N=121). The feedback was analyzed quantitatively and qualitatively to establish user appraisals of the online information, whether and how caregivers applied the information and ways it could be improved.

RESULTS

The majority of users (86.4% to 97.4%) found the various sections of the website useful. At follow-up, nearly 93% of caregivers reported that the information was relevant to them and 96% thought it would help others. Most respondents said that the information was supportive and encouraged adaptive control appraisals. However, a few respondents who were experiencing complex family problems, or who cared for a person with severe chronic bipolar disorder did not appraise it as positively. Nevertheless, over two-thirds of the caregivers reported using the information. Optional interactive features were recommended to maximize benefits.

CONCLUSIONS

Overall, http://www.bipolarcaregivers.org was appraised positively and used. It appears useful to close family and friends seeking basic information and reassurance, and may be an inexpensive way to disseminate guidelines for caregivers. Those who care for people with more severe and chronic bipolar disorder, or who have complex family problems might benefit from more specialized interventions, suggesting the importance of a stepped-care approach to supporting caregivers. The potential of evidence-based, collaboratively developed information websites to enhance caregiver and consumer outcomes merits further investigation.

The science and practice of lithium therapy

INTRODUCTION

Despite more that 60 years of clinical experience, the effective use of lithium for the treatment of mood disorder, in particular bipolarity, is in danger of becoming obsolete. In part, this is because of exaggerated fears surrounding lithium toxicity, acute and long-term tolerability and the encumbrance of life-long plasma monitoring. Recent research has once again positioned lithium centre stage and amplified the importance of understanding its science and how this translates to clinical practice.

OBJECTIVE

The aim of this paper is to provide a sound knowledge base as regards the science and practice of lithium therapy.

METHOD

A comprehensive literature search using electronic databases was conducted along with a detailed review of articles known to the authors pertaining to the use of lithium. Studies were limited to English publications and those dealing with the management of psychiatric disorders in humans. The literature was synthesized and organized according to relevance to clinical practice and understanding.

RESULTS

Lithium has simple pharmacokinetics that require regular dosing and monitoring. Its mechanisms of action are complex and its effects are multi-faceted, extending beyond mood stability to neuroprotective and anti-suicidal properties. Its use in bipolar disorder is under-appreciated, particularly as it has the best evidence for prophylaxis, qualifying it perhaps as the only true mood stabilizer currently available. In practice, its risks and tolerability are exaggerated and can be readily minimized with knowledge of its clinical profile and judicious application.

CONCLUSION

Lithium is a safe and effective agent that should, whenever indicated, be used first-line for the treatment of bipolar disorder. A better understanding of its science alongside strategic management of its plasma levels will ensure both wider utility and improved outcomes.

Palliative models of care for later stages of mental disorder: maximizing recovery, maintaining hope, and building morale

BACKGROUND

The concept of staging of disease in psychiatry has developed over the past years. A neglected component of this model pertains to people in the advanced stages of a mental illness, who remain symptomatic and functionally impaired despite treatment. These patients are often high service utilizers, receiving complex multimodal treatments where the balance of risk and benefit shifts perceptibly. In this paper, we argue the need to adopt 'palliative' models of care for some individuals, and consider changing the therapeutic goals to follow care pathways similar to those used in other chronic and refractory medical illnesses.

METHOD

Data was sourced by a literature search using Medline and a hand search of scientific journals. Relevant articles were selected.

RESULTS

Clinical staging can help us better define subgroups of patients who will benefit from different goals and treatment. In the most advanced stage group, we find patients with persistent symptoms and treatment resistance. In these situations, it may be preferable to follow some of the principles of palliative care, which include the setting of attainable goals, reduction of side-effects, limited symptom control, targeting identified psychological and social problems, and attempting to attain the best quality of life for these patients and their families.

CONCLUSIONS

It is in the interest of those in the advanced phases of a disorder that clinicians acknowledge the limitations of treatment and actively attempt to plan treatment utilizing alternate models. It is essential to be clear that such approaches do not equate to the abandonment of care, but rather to the reconceptualizing of feasible and personalized treatment goals, a rebalancing of the risks and benefits of intervention, the management of illness behaviour, and the approaches that allow the patient to live gainfully within their limitations.