A systematic review of dramatherapy interventions used to support adults with psychosis

BACKGROUND

Psychiatric treatment of psychosis often comprises therapeutic and psychotropic combinations. Dramatherapy is often utilised in health services with this population, particularly when clients struggle to engage with talking therapies because of complex presentations, experience preverbal trauma, neurodiversity challenges and/or communication difficulties. Dramatherapy as a therapeutic intervention is recognised by health regulating bodies but as yet has not yet been systematically reviewed.

AIMS

To synthesise existing peer-reviewed empirical research literature and gather evidence regarding dramatherapy used to support adults with psychosis; To collate and understand the intervention methods of dramatherapy as a treatment to support adults experiencing psychosis; To assess the effect of dramatherapy on adults with psychosis, by collating qualitative and quantitative outcome measures, where reported in included research.

METHODS

Literature was sourced through database searches (CINAHL, EMBASE, COCHRANE, PsycINFO, PubMed, Scopus, and APA PsycNet) and hand searches. 8541 papers were screened, and 11 met inclusion criteria for synthesis. Findings related to aims were narratively synthesised, before being thematically analysed.

RESULTS

Participant characteristics of age, gender, ethnicity, and socio-economic background were heterogeneous. Participants across studies often had multiple diagnoses, and unknown complexities making recovery through standard treatment unachievable. Presentations included episodes of psychosis, schizophrenia, and dual-diagnoses of mental health challenges and intellectual difficulties. Positive effects found the use of dramatherapy include: New perspectives; Improved relationships; Ability to make choices with reduced anxiety; Understanding of self; Reduced psychotic symptoms. Quantitative data substantiated qualitative findings, and effect indicated changes in social functioning, behaviours, and symptoms following dramatherapy intervention.

IMPLICATIONS

Systematic findings will support practitioners to implement evidence-based practice and to improve treatment provision for adults with psychosis. Further methodologically sound research into the field is encouraged to advance understanding of dramatherapy interventions for adults with psychosis.

A systematic review of dramatherapy interventions used to alleviate emotional distress and support the well-being of children and young people aged 8-18 years old

Background

Dramatherapy, a creative form of psychotherapy, may be a useful treatment for child and adolescent mental health. As there is a growing evidence base, this systematic review sought to identify, describe and evaluate dramatherapy with children and adolescents who were experiencing emotional distress (anxiety, depression and trauma) in order to inform future research in this area.

Methods

Seven databases (PsychInfo, PubMed, Scopus, Web of Science, CINAHL, EMBASE and Cochrane) were searched for peer-reviewed articles exploring dramatherapy as a treatment for child and adolescent emotional distress. Hand searches of relevant journals were also conducted. Two reviewers coded articles for eligibility and independently appraised papers using the Joanna Briggs Institute Critical Appraisal Tools. Details relating to intervention and participant characteristics were extracted and, where data were available, effect sizes on measures relating to emotional distress were calculated.

Results

Fifteen papers were included. Studies showed that dramatherapy was often delivered in schools (46%) and clinical settings (20%) and was more frequently delivered to adolescents (53%) (>11 years) than children (26%) (8-11 years). Dramatherapy was used as a treatment for diagnostically heterogeneous groups (40%), for emotional and behavioural difficulties (33%) and following a shared, traumatic, experience (20%). Seven papers reported relevant quantitative data however, just three of these studies were controlled and none were blinded. Pre-to-post intervention effect sizes ranged from d = 0.17 to d > 2 yet samples were small and participant response to treatment was not always consistent. The largest effects were seen in dramatherapy employed following trauma and in clinical settings. Medium to large effects were also seen in early intervention school-based dramatherapy.

Conclusion

Despite promising results with regards to the treatment of child and adolescent emotional distress, the evidence base for dramatherapy is small and methodologically flawed. Larger, methodologically robust trials should test the efficacy of dramatherapy in future research.

Improving access to primary care and annual health checks for people who have a learning disability: a multistakeholder qualitative study

OBJECTIVES

To investigate key stakeholders' views on how to improve access to primary care in general practice settings for people with learning disabilities (or intellectual disabilities). Further to explore how inequalities and barriers in specific areas including annual health checks might be addressed.

DESIGN

A qualitative study design was used with data collected during focus groups, interviews and open-response surveys; data analysis was thematic and informed by stakeholder consultation. Processes to facilitate quality included triangulation of stakeholder perspectives, triangulation of data collection methods and checking interpretation of findings with participants.

SETTING

UK regional services including learning disability organisations, primary care general practitioner (GP) clinical practice networks and supported housing organisations.

PARTICIPANTS

Sixteen people participated in the study: four people with learning disabilities participated in a focus group; four relatives completed an interview or survey; eight GPs, practice nurses and supported housing managers participated in interviews.

RESULTS

Five overarching themes describing approaches to improve primary care access for people with learning disabilities were identified including: prioritisation, proactivity, innovation and improvement, personalisation and prevention and follow-up. Definitions of themes were described and illustrated with quotes. Ten recommendations informed by the thematic analysis, stakeholder consultation, research and primary care guidance were codeveloped with people with learning disabilities.

CONCLUSIONS

All stakeholders identified problems, with primary care interfaces being misaligned with the needs of people with learning disabilities. The recommendations informed by all stakeholders can be used to guide development of service provision to better meet the needs of people with learning disabilities in primary care. Future research should explore professionals' understanding of reasonable adjustments.

Advances for future working following an online dramatherapy group for adults with intellectual disabilities and mental ill health during the COVID-19 pandemic: A service evaluation for Cumbria, Northumberland Tyne and Wear NHS Foundation Trust

Background

During the COVID-19 pandemic, social distancing measures were enforced and the national lockdown underlined our reliance on virtual means as a way to communicate. This new way of interacting highlighted that people with an intellectual disability were a large proportion of a digitally excluded population.

Methods

A service evaluation, using a mixed method design in the form of four self-reported outcome measures and qualitative feedback.

Findings

Clinical services need to continue when face to face sessions are not possible. Remote groups can be an alternative option not only when self-isolating due to pandemics but when living in remote locations, having physical health problems or excessive expenses and travel costs.

Conclusions

Online dramatherapy groups can be a beneficial alternative when face to face groups are not possible or challenging to attend due to access difficulties. Online groups can offer opportunities to meet with peers, build relationships, improve confidence and learn new skills in technology.

A systematic review of community psychosocial group interventions for adults with intellectual disabilities and mental health conditions

BACKGROUND

People with intellectual disabilities have a high risk of developing mental ill-health. Treatment is often neglected and diagnosis is misattributed to a person's disability. Standard psychosocial interventions can improve a person's well-being. This review aimed to understand what interventions are being delivered, any benefits, and future recommendations.

METHODS

Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were followed, and the review registered with PROSPERO-CRD42020160254. Databases searched included: MEDLINE, Embase, and PsycINFO. A framework synthesis approach was used to present the findings.

RESULTS

There are limited psychosocial interventions offered for this population. When groups are delivered having a creative element, multiple activities over a short period of time, with breaks and group rules outcomes can be improved.

CONCLUSIONS

Adaptations and reasonable adjustments should be used specifically to a person's ability. A mixed-method design allows people to share their experiences alongside quantitative data that provides clinical information.

A randomised controlled feasibility study of interpersonal art psychotherapy for the treatment of aggression in people with intellectual disabilities in secure care

BACKGROUND

Rates of aggression in inpatient secure care are higher than in other psychiatric inpatient settings. People with intellectual disabilities in secure care require adapted psychological treatments. Interpersonal art psychotherapy incorporates the use of creative art making approaches by participants, thus reducing sole reliance upon verbal interactions during psychotherapy for people who may have communication difficulties. During interpersonal art psychotherapy, participants are individually supported by their therapist to consider how they conduct relationships. This includes the influence and impact of interpersonal issues resulting in repeated patterns of conflict. The key feasibility objectives were to assess recruitment and retention rates, follow-up rates and trial procedures such as randomisation, allocation and identifying any practical or ethical problems. In addition, a preliminary 'signal' for the intervention was considered and an indicative sample size calculation completed. The acceptability of a potential third trial arm attentional control condition, mindful colouring-in, was assessed using four single-case design studies and a UK trial capacity survey was conducted.

METHODS

Adult patients with intellectual disabilities in secure care were recruited and randomised to either interpersonal art psychotherapy or delayed treatment in this multi-site study. Outcomes were assessed using weekly observations via the Modified Overt Aggression Scale and a range of self-report measures. Within study reporting processes, qualitative interviews and a survey were completed to inform trial feasibility.

RESULTS

Recruitment procedures were successful. The target of recruiting 20 participants to the trial from multiple sites was achieved within 8 months of the study opening. All participants recruited to the treatment arm completed interpersonal art psychotherapy. Between-group differences of interpersonal art psychotherapy versus the delayed treatment control showed a 'signal' effect-size of .65 for total scores and .93 in the verbal aggression sub-scale. There were no amendments to the published protocol. The assessment of key feasibility objectives were met and the trial procedures were acceptable to all involved in the research.

CONCLUSION

This study suggested that a randomised controlled trial of interpersonal art psychotherapy is acceptable and feasible.

TRIAL REGISTRATION

ISRCTN14326119 (Retrospectively Registered).

Using Arts-Based Therapies to Improve Mental Health for Children and Young People With Physical Health Long-Term Conditions: A Systematic Review of Effectiveness

Background: Children with physical health long-term conditions (LTCs) have increased risk of mental health difficulties relative to healthy peers. However, availability of psychological support integrated into pediatric physical health settings is limited, and there are long waiting times for access to child mental health services. Arts-based therapies involve using creative media to develop a therapeutic relationship, and offer a potential alternative to talking-based therapies. The aim of this systematic review is to establish the effectiveness of arts-based therapies for improving the mental health of children with physical health LTCs.

Methods: The review protocol was published on PROSPERO. Four electronic databases were searched (Medline, Embase, Cinahl, and PsycINFO), plus hand searches of two key journals and relevant reviews, and forward/back citations searches of selected articles were conducted. The Effective Public Health Practice Project (EPHPP) Quality Assessment Tool was used to assess bias in selected articles. Second reviewers completed 10% of article screening and 20% of bias assessments. The findings were synthesized narratively.

Results: Sixteen studies met inclusion criteria and demonstrated some improvements on indicators of mental health and well-being including quality of life, coping behaviors, anxiety, self-concept, and mood. However, replication across interventions and outcomes was absent. Overall, the quality of evidence of effectiveness in the studies reviewed was moderate/weak. This was due to bias in study design; other limitations included a lack of detail on intervention components, e.g., use of a manual, and single recruitment sites.

Conclusions: The heterogeneity of existing research evaluating arts-based therapies for children with physical health LTCs limits conclusions about effectiveness. Suggestions are made to inform the design of future research studies to help build a robust evidence base.

Don't go chasing artificial waterfalls: Artificial line limits and cascading failures in power grids

Research on cascading failures in power-transmission networks requires detailed data on the capacity of individual transmission lines. However, these data are often unavailable to researchers. Consequently, line limits are often modeled by assuming that they are proportional to some average load. However, there is scarce research to support this assumption as being realistic. In this paper, we analyze the proportional loading (PL) approach and compare it to two linear models that use voltage and initial power flow as variables and are trained on the line limits of a real power network that we have access to. We compare these artificial line-limit methods using four tests: the ability to model true line limits, the damage done during an attack, the order in which edges are lost, and accuracy ranking the relative performance of different attack strategies. We find that the linear models are the top-performing method or are close to the top in all the tests we perform. In comparison, the tolerance value that produces the best PL limits changes depending on the test. The PL approach was a particularly poor fit when the line tolerance was less than two, which is the most commonly used value range in cascading failure research. We also find indications that the accuracy of modeling line limits does not indicate how well a model will represent grid collapse. The findings of this paper provide an understanding of the weaknesses of the PL approach and offer an alternative method of line-limit modeling.

Protocolised Approach to End-of-Life Care in the ICU—The ICU PALCare Pilot Project

International literature on end-of-life care in intensive care units (ICUs) supports the use of ‘protocol bundles’, which is not common practice in our 18-bed adult general ICU in Sydney, New South Wales. We conducted a prospective observational study to identify problems related to end-of-life care practices and to determine whether there was a need to develop protocol bundles. Any ICU patient who had ‘withdrawal’ of life-sustaining treatment to facilitate a comfortable death was eligible. Exclusion criteria included organ donors, unsuitable family dynamics and lack of availability of research staff to obtain family consent. Process-of-care measures were collected using a standardised form. Satisfaction ratings were obtained using de-identified questionnaire surveys given to the healthcare staff shortly after the withdrawal of therapy and to the families 30 days later. Twenty-three patients were enrolled between June 2011 and July 2012. Survey questionnaires were given to 25 family members and 30 healthcare staff, with a high completion rate (24 family members [96%] and 28 staff [93.3%]). Problems identified included poor documentation of family meetings (39%) and symptom management. Emotional/spiritual support was not offered to families (39.1%) or ICU staff (0%). The overall level of end-of-life care was good. The overwhelming majority of families and healthcare staff were highly satisfied with the care provided. Problems identified related to communication documentation and lack of spiritual/emotional support. To address these problems, targeted measures would be more useful than the adoption of protocol bundles. Alternate models of satisfaction surveys may be needed.

Extended adherence support by community pharmacists for patients with hypertension: a randomised controlled trial

Objective

To determine the effects of a patient-centred intervention by community pharmacists on adherence to treatment for hypertension.

Study design

Randomised controlled trial.

Method

Randomisation was at pharmacy level. Pharmacists in the intervention group used a structured, brief questioning protocol to identify patients' medication-related problems and their information needs relating to hypertension and its treatment. Advice, information and referral to the general practitioner (GP) were provided by the pharmacist, based on patients' responses. Pharmacists in the control group provided usual care. The intervention was delivered three times at approximately two-month intervals. Blood pressure measurements were collected retrospectively from GP medical records. Patients completed feedback questionnaires at baseline and post-study. The questionnaire comprised a self-reported adherence measure and explored satisfaction with pharmaceutical services.

Setting

Twenty community pharmacy sites (11 intervention and nine controls) in one health authority area in England.

Outcome measures

Control of blood pressure; patient satisfaction with pharmaceutical services; self-reported adherence.

Results

In total, 180 patients (101 intervention and 79 control) from 43 general medical practices completed the trial. Patients whose blood pressure was uncontrolled prior to the study were more likely to become controlled in the intervention group (P<0.05). Most of the effect on self-reported adherence was seen after the first intervention. Patient satisfaction was high prior to the study and was increased in the intervention group after the study. The increase was statistically significant for five items relating to communication between pharmacist and patient.

Conclusion

A simple intervention delivered by community pharmacists produces positive effects on blood pressure control, self-reported adherence and on patient satisfaction with pharmaceutical services.

Herd-level risk factors associated with tuberculosis breakdowns among cattle herds in England before the 2001 foot-and-mouth disease epidemic

A case-control study of the factors associated with the risk of a bovine tuberculosis (TB) breakdown in cattle herds was undertaken within the randomized badger culling trial (RBCT). TB breakdowns occurring prior to the 2001 foot-and-mouth disease epidemic in three RBCT triplets were eligible to be cases; controls were selected from the same RBCT area. Data from 151 case farms and 117 control farms were analysed using logistic regression. The strongest factors associated with an increased TB risk were movement of cattle onto the farm from markets or farm sales, operating a farm over multiple premises and the use of either covered yard or 'other' housing types. Spreading artificial fertilizers or farmyard manure on grazing land were both associated with decreased risk. These first case-control results from the RBCT will be followed by similar analyses as more data become available.

No evidence of Mycobacterium avium subsp. paratuberculosis in in vitro produced cryopreserved embryos derived from subclinically infected cows

The aim of the project was to ascertain if Mycobacterium avium subsp. paratuberculosis (Map) could be cultured from frozen-thawed in vitro produced (IVP) embryos derived from cows with subclinical Johne's disease (JD). Straws of 109 IVP embryos were obtained from 267 cumulus-oocyte-complexes (COCs) collected from 12 clinically normal cows in which antibodies against Map were detected in blood by an enzyme-linked immunosorbent assay (ELISA). These embryos were processed, washed using the standard protocol as described by the International Embryo Transfer Society (IETS) and frozen in a commercial IVP embryo laboratory. Of the 12 donor cows, 11 had histopathological or bacteriological evidence of infection at post-mortem inspection. The frozen embryos were thawed and the contents of the straws were cultured using the radiometric mycobacterial culture method. No Map was detected in any of the 109 embryos or freezing media. This suggests that the use of in vitro produced and cryopreserved embryos derived from cows with subclinical JD poses very low, if any, risk of spreading infection to susceptible animals.

Overcoming barriers to hepatitis B immunisation by a dedicated hepatitis B immunisation service

AIMS

To determine the effectiveness of a selective hospital based hepatitis B immunisation programme and the barriers to be overcome in obtaining a successful outcome.

METHODS

Retrospective case note review of 265 infants born over a five year period to hepatitis B carrier mothers at a university affiliated hospital in Hackney, London.

RESULTS

A total of 242 infants (91%) were fully vaccinated; 217 (82%) had serology; 31 required booster doses. Percentages failing to reach second, third vaccinations, and serology on schedule rose exponentially (7%, 18%, 33% respectively). Mobility was high (25%) and significantly affected outcome. A total of 95% Hackney resident babies were fully vaccinated compared with 78% non-residents. Uptake of routine immunisations was higher in Hackney residents than non-residents and greater in those who were eligible for hepatitis B vaccine. Name changes occurred in 35%. Translation requirements were high (85% for Turkish, Vietnamese, and Asian families). Requirements for specific postnatal counselling of mothers and hepatology referral fell significantly during the course of the study. Only seven of 22 babies born in 1995 in Tower Hamlets compared with 53 of 58 Hackney babies received a full vaccination course in non-hospital based primary care.

CONCLUSION

In inner city areas with high prevalence of hepatitis B carriage, mobility, and diverse ethnicity, a dedicated centralised immunisation service can be highly effective, provided that adequate support services (translation, counselling, and parental referral) are available.

Louisiana's Vanishing Wetlands: Going, Going

An ambitious $14 billion plan known as Coast 2050 attempts to protect more than 10,000 square kilometers of Louisiana's wetlands, which are disappearing at a rate of up to 90 square kilometers per year, one of the highest rates of land loss in the world. But a number of unanswered scientific questions swirl around the plan. And it could run afoul of powerful interests in the shipping, petroleum, and fishing industries.

Bovine tuberculosis: towards a future control strategy

The Independent Scientific Group on Cattle TB was appointed by the Government in 1998 to implement and develop the research recommendations of the 1997 Krebs report on bovine tuberculosis in cattle and badgers. In this article, members of the group discuss the approach they are adopting in attempting to ensure that future control strategies are scientifically based. In a second article, to be published in next week's Veterinary Record, the group will consider the extent to which efforts to control the disease in cattle may be constrained by limitations in current testing procedures.

Diabetes in the indigenous population of the Commonwealth of the Northern Mariana Islands

Diabetes prevalence and complications rates were examined for the indigenous population of the Commonwealth of the Northern Mariana Islands in the western Pacific. Diabetes is common, with 4% of the population and 11% of adults having diagnosed diabetes. Diabetes is more common among females and islanders of Carolinian descent. End stage renal disease, hospitalizations for pneumonia, non-traumatic lower extremity amputations and retinopathy are more common than expected (with relative risks of 3.9, 3.0, 1.5 and 1.3, respectively, compared with diabetics in US), while diabetes-related mortality and hospitalizations for ischemic heart disease/cerebrovascular disease are less (with relative risks of 0.9 and 0.8). Implications for primary and secondary prevention of diabetes and its complications are discussed.

The Vanderbilt University fast track to IAIMS: transition from planning to implementation

Vanderbilt University Medical Center is implementing an Integrated Advanced Information Management System (IAIMS) using a fast-track approach. The elapsed time between start-up and completion of implementation will be 7.5 years. The Start-Up and Planning phases of the project are complete. The Implementation phase asks one question: How does an organization create an environment that redirects and coordinates a variety of individual activities so that they come together to provide an IAIMS? Four answers to this question are being tested. First, design resources to be "scalable"--i.e., capable of supporting enterprise-wide use. Second, provide information technology planning activities as ongoing core functions that direct local efforts. Third, design core infrastructure resources to be both reusable and expandable at the local level. Fourth, use milestones to measure progress toward selected endpoints to permit early refinement of plans and strategies.

Binding and agonist/antagonist actions of M35, galanin(1-13)-bradykinin(2-9)amide chimeric peptide, in Rin m 5F insulinoma cells

The chimeric peptide M35 [galanin(1-13)-bradykinin(2-9) amide] is a high-affinity galanin receptor ligand acting as a galanin receptor antagonist in the rat spinal cord, rat hippocampus and isolated mouse pancreatic islets. We have radiolabelled M35 and performed equilibrium binding studies with [125I]M35 on the rat pancreatic beta-cell line Rin m 5F, whereby we show the existence of high-affinity binding site (KD = 0.9 +/- 0.1 nM) with a Bmax of 72 +/- 3 fmol/mg protein. Galanin displaces [125I]M35 with the same affinity (KD = 1 nM) as it displaces [125I]galanin. Displacement of [125I]galanin by M35 from Rin m 5F cell membranes shows the presence of two binding sites for M35 with KD-values of 0.3 +/- 0.1 nM and 0.52 +/- 0.03 microM, respectively. The GTP- and pertussis toxin-sensitivity of M35 binding to Rin m 5F membranes shows that binding of [125I]M35 is almost completely abolished by the presence of GTP or after pertussis toxin treatment of the cells, indicating an agonist-like binding of M35 to the galanin receptors. M35 has a dual effect on the galanin mediated inhibition of forskolin stimulated cyclic AMP production in Rin m 5F cells: at low concentrations M35 antagonises the effect of galanin, whereas at concentrations above 10 nM M35 acts as a galanin receptor agonist. These agonist-like effects of galanin and M35 are not additive, thus the mixed agonist/antagonist properties arise from the chimeric nature of M35[galanin(1-13)-bradykinin(2-9)amide] acting solely at galanin receptors.

Clinical hypersensitivity to specific aerosol challenge in parenterally immunized calves

This paper reports an experiment designed to demonstrate that the calf lung can be sensitized to a specific respirable challenge following parenteral immunization with a nonliving antigen (human serum albumin). The possibility that immune-mediated injury could subsequently interfere with nonspecific mucosal defenses was also investigated by infecting calves with Pasteurella haemolytica after the antigen challenge and assessing pulmonary clearance of the organism. The results indicated that specific aerosol challenge produces reversible signs of respiratory hypersensitivity and that persistence of incidental infection in the upper respiratory tract is potentiated. Since the calves were sensitized by an immunization regime which imitated conventional vaccination, this study highlights the potential dangers of inactivated parenteral respiratory vaccines.

Eye protection for patients undergoing oral surgery

The risk to the eyes during oral surgical procedures is pointed out, and a simple method of protection is described.

The nature of the local immune system of the bovine mammary gland

The origin of the immunoglobulins of bovine colostrum and milk were examined by using radiolabeled protein. Colostrum was found to consist mainly of immunoglobulin derived from serum, although there was some local synthesis. In lactation the immunoglobulins of milk were almost entirely serum derived. The local immune system was very inactive but could be stimulated to activity by local immunization. The immunoglobulin profiles of the secretion from the stimulated gland were still relatively deficient in IgA compared to other species, notably the pig.