Guided self-help for anxiety among Huntington's disease gene expansion carriers (GUIDE-HD) compared to treatment as usual: a randomised controlled feasibility trial

BACKGROUND

Huntington's disease (HD) is an adult-onset genetic neurodegenerative condition associated with cognitive decline, motor impairments, and emotional difficulties. Anxiety affects up to 71% of HD gene expansion carriers (i.e., those with the version of the gene that causes HD) and can negatively impact quality of life, worsen other HD symptoms, and increase suicide risk. Therefore, helping people with their anxiety should be a clinical priority. A significant evidence base now exists for low-cost talking therapies for anxiety, such as guided self-help, and with people with other neurodegenerative conditions (e.g., Parkinson's disease). However, this type of intervention has not been specifically assessed with HD gene expansion carriers.

METHODS

This protocol describes an exploratory randomised controlled feasibility study of a psychological intervention for anxiety for HD gene expansion carriers. The 10 session guided self-help intervention ('GUIDE-HD') is based on a blend of second and third wave cognitive behavioural models of anxiety (cognitive behaviour therapy [CBT] and acceptance and commitment therapy [ACT]) and is adapted to meet the specific needs of an HD population. This study will compare guided self-help with treatment as usual (TAU), with 15 HD gene expansion carriers randomly allocated to each group. Participants will be recruited across the UK. Quantitative data will be collected pre-intervention, immediately post-intervention, 3-month post-intervention and 6-month post-intervention. Qualitative data will be collected at one month post-intervention from participants, including HD carers. The data will be analysed to assess whether the current intervention and study design are feasible to progress to a larger randomised controlled trial. Feasibility has been defined in terms of recruitment rate, retention rate to both trial arms, intervention adherence, and acceptability of the intervention and measurement tools.

DISCUSSION

Given the lack of evidenced interventions to date to support the wellbeing of people with the expanded Huntington's gene, this study will assess the feasibility of progressing this particular intervention to a full trial. To try and increase the acceptability of the intervention, a number of stakeholders, including those affected by HD and in caring roles, have been fundamental to the creation of the intervention (e.g., therapy manual, planned therapy process) to date.

TRIAL REGISTRATION

Trial ID: ISRCTN47330596 . Date registered: 28/09/2022. Protocol version and date: Version 2, 09/06/22. Trial sponsor organisation and contact: Leicestershire Partnership NHS Trust (Dave Clarke). Role of sponsor: Overall responsibility for the conduct and governance of the trial. Role of funder: Review of initial research proposal.

Arts-based methods for hallucination research

INTRODUCTION

Neurocognitive models of hallucinations posit theories of misattribution and deficits in the monitoring of mental or perceptual phenomena but cannot yet account for the subjective experience of hallucinations across individuals and diagnostic categories. Arts-based research methods (ABRM) have potential for advancing research, as art depicts experiences which cognitive neuropsychiatry seeks to explain.

METHODS

To examine how incorporating ABRM may advance hallucination research and theories, we explore data on the lived experiences of hallucinations in psychiatric and neurological populations. We present a multiple case study of two empirical ABRM studies, which used participant-generated artwork and artist collaborations alongside interviews.

RESULTS

ABRM combined with interviews illustrated that hallucinations were infused with sensory features, characterised by embodiment, and situated within lived circumstances. These findings advance neurocognitive models of hallucinations by nuancing their multimodal nature, illustrating their embodied feelings, and exploring their content and themes. The process of generating artworks aided in disclosing difficult to discuss hallucinations, promoted participant self-reflection, and clarified multimodal details that may have been misconstrued through interview alone. ABRM were relevant and acceptable for participants and researchers.

CONCLUSION

ABRM may contribute to the development of neurocognitive models of hallucinations by making hallucination experiences more visible, tangible, and accessible.

The feeling, embodiment and emotion of hallucinations in first episode psychosis: A prospective phenomenological visual-ecological study using novel multimodal unusual sensory experience (MUSE) maps

BACKGROUND

Research and practice typically focus upon unimodal hallucinations, especially auditory verbal hallucinations. Contemporary research has however indicated that voice-hearing may co-occur within a broader milieu of feelings, and multimodal hallucinations may be more common than previously thought.

METHODS

An observational design asked participants to prospectively document the feeling and modality of hallucinations for one week prior to an interview. Novel visual diary methods involving drawing, writing and body-mapping generated 42 MUSE maps (multimodal unusual sensory experience), analysed with a participatory qualitative method. Twelve people took part: all experiencing hallucinations daily, accessing early intervention in psychosis services, given psychotic-spectrum diagnoses, and living in the community. The study took place during a seven-month period in 2018 at Leicestershire and Rutland's Psychosis Intervention and Early Recovery service (UK).

FINDINGS

All documented hallucinations co-occurred with bodily feelings. Feelings were localised to specific body areas, generalised across the body and extended beyond the body into peripersonal space. Co-occurring emotional feelings most commonly related to confusion, fear and frustration.

INTERPRETATION

Hallucinations were characterised by numerous feelings arising at once, often including multimodal, emotional, and embodied features. Within this study, the immediate feeling of hallucination experiences were readily communicated through prospective, visual, and ecological information gathering methods and particularly those which offer multiple modes of communication (e.g. body-map, visual, written, oral). Uptake of visual, ecological and prospective methods may enhance understandings of lived experiences of hallucinations.Funding: University of Leicester.

Treatment of severe perinatal mood disorders on a specialized perinatal psychiatry inpatient unit

Perinatal patients with bipolar and psychotic mood disorder exacerbations are challenging to treat and often receive suboptimal care. We sought to examine the treatment patterns and outcomes on one of the only US-based Perinatal Psychiatry Inpatient Units (PPIU). Perinatal patients admitted to the PPIU completed self-report measures at admission and before discharge. Retrospective chart reviews extracted history, diagnoses (current and past), and medication treatment. Patients who had discharge diagnoses of bipolar disorder, major depression with psychotic features, or postpartum psychosis were included. Forty-seven met the diagnostic inclusion criteria. Over an average length of stay (ALOS) of 9.96 days, there was significant improvement in depressive and anxiety symptoms and daily functioning (Work and Social Adjustment Scale). Psychiatric comorbidity was common. Polypharmacy was utilized in 87 %. The most common medications prescribed at discharge were antipsychotics, alone or in combination with mood stabilizers or antidepressants. ECT was performed in 10 % of cases. The complexity of patients with severe mood disorders or psychosis admitted to the PPIU supports individualized treatment plans that address both primary diagnosis and psychiatric comorbidities. Our results provide important information that can be disseminated to others to improve clinical outcomes for severe perinatal mood disorders.

Promoting effective practice in secondary care

BACKGROUND

This qualitative study aimed to explore the views of key stakeholders regarding the role that public health professionals have or should have in the provision of effective health care within the National Health Service.

METHODS

A national (England) questionnaire survey generated a sample for qualitative telephone interviews and two site case studies. The interviews were conducted in three stages: first, 27 interviews were based on assessed reported levels of organizational activity, including non-respondents; next, views in six areas were consolidated by extra interviews; finally, two extra areas were visited for individual and group interviews. The interviews were analysed for salient themes.

RESULTS

There was a widespread view that public health had not delivered its potential. Many Trusts currently wanted public health to have influence over commissioning, provide health needs assessments and epidemiological skills, and provide a strategic focus and unbiased advice. Evaluation of actual activity varied widely; local history and congruent personalities seemed to be associated with perceived success. In some cases there was mutual suspicion between Health Authorities and Trusts. Public health was often perceived by Trusts to have been marginalized. This perception was not shared by Public Health Consultants, who highlighted lack of resources as a reason for lack of involvement. The contribution of public health professionals working in Trusts was highly regarded. Barriers included overcoming initial prejudice and combating isolation within Trusts. There were four categories of response in respect of the potential future role for public health in implementing effective health care: no role; collaborative working between Health Authority Public Health Departments and Trusts; deployment of public health workers within Trusts, and an undecided group. Overall, the skills of public health, especially strategic vision and population perspectives, were seen as valuable but as yet unrealized.

CONCLUSIONS

Public health skills (but not necessarily professionals) may be valuable in implementing effective health care in Trusts. However, public health professionals must refocus and market their skills to Trusts if the discipline is to play a key role in this task.

The long-term effect of quetiapine (Seroquel TM ) monotherapy on weight in patients with schizophrenia

INTRODUCTION

Quetiapine (Seroquel TM ) is an atypical antipsychoticdrug with demonstrated efficacy and tolerability. In particular, placebo-level extrapyramidal symptoms (EPS) across the entire dose range and a low propensity to cause sexual dysfunction suggest it may be associated with greater patient acceptability than alternative treatments. However, other side-effects, such as weight gain, may also have a significant impact on treatment acceptability.

METHOD

We report the long-term weight changes observed in a cohort of 427 patients with schizophrenia from controlled and open-label extension (OLE) trials, in which quetiapine (mean dose 475 mg/day after 1 year) was the only antipsychotic medication during the OLE period.

RESULTS

In these patients, there was no overall effect on weight across the body mass index (BMI) spectrum. There were no dose-related effects on weight, and only one patient withdrew from treatment due to an adverse event of weight gain. Quetiapine appeared to have a weightneutral or 'normalizing' effect, with a tendency towards favourable shifts in bodyweight in underweight patients (BMI<18.5 kg/m 2 ) and severely obese patients (BMI>35 kg/m 2 ).

CONCLUSION

These results indicate that long-term weight changes with quetiapine monotherapy are minimal and potentially beneficial, and do not appear to raise the medical concerns associated with some other atypical agents.

Successful surgical repair in a patient with mitral stenosis, calcified left atrium and severe tricuspid regurgitation with a giant right atrium

Successful mitral valve replacement and tricuspid annuloplasty were performed on a 66-year-old woman who had a calcified left atrium, giant right atrium, calcified mural thrombus and normal pulmonary pressures. Successful repair in such cases depends on an adequate preoperative investigation and a surgical approach tailored to the individual.

Obstructive sleep apnea and cardiac index

Seventeen men (age range, 21 to 58 years) with severe obstructive sleep apnea syndrome (OSAS) documented by nocturnal polysomnography underwent hemodynamic investigations during sleep. We studied the evolution of the cardiac index during apneic events in both NREM and REM sleep using the thermodilution technique. Regardless of the patient's age, the sleep state, or the mechanism inducing the OSAS, the cardiac index decreased significantly from baseline during an apneic event and increased significantly from baseline at the resumption of ventilation.

Cyclical variation of the heart rate in sleep apnoea syndrome. Mechanisms, and usefulness of 24 h electrocardiography as a screening technique

400 sleep-apnoeic patients with an intact autonomic nervous system underwent twenty-four-hour electrocardiography with simultaneous polygraphy recording at night. At onset of sleep apnoea all showed progressive bradycardia, followed by abrupt tachycardia on resumption of breathing. The electrocardiographic pattern, which is identifiable by computer analysis, can be used as a screening tool for sleep apnoea; it was not seen in controls without sleep apnoea syndrome. A subgroup of patients with sleep apnoea and impairment of autonomic nervous control of the heart (heart transplants, autonomic neuropathy, Shy-Drager syndrome) did not show the cyclical heart rate pattern. In obstructive sleep apnoeic patients with normal autonomic nervous function, atropine sulphate blocked the pattern by eliminating the bradycardia component, while 100% oxygen, even at high rates of administration, caused only moderate blunting of the heart rate variation. The electrocardiographic changes observed in sleep apnoea syndrome are therefore mediated by the autonomic nervous system; hypoxia is not the only factor involved.

Entrapment of the popliteal artery

Popliteal artery entrapment is a rare but recognized cause of vascular insufficiency of the lower extremity. The authors describe the condition in a 26-year-old man. Diagnosis depends on arteriographic demonstration of the lesion. Treatment is surgical and should consist of either a bypass procedure or excision with graft interposition. Acute onset of peripheral vascular symptoms in a young person should arouse suspicion of such a lesion.

Dietary fibre and the irritable bowel syndrome

The dietary fibre intake of 25 patients with the irritable bowel syndrome was assessed by dietary recall over one week for the period before onset of symptoms, at diagnosis and after six months treatment with bran and a fibre-rich diet, and compared with controls matched for age and sex. Mean intake of patients fell from 20.2 g per day before onset of symptoms to 17.8 g at diagnosis (n.s.), when it was significantly less than the controls' intake of 22.6 g (P less than 0.01). The 20 patients who improved with treatment increased their intake from 18.9 g to 24.8 g (P less than 0.02); the five patients who did not improve did not increase their intake significantly (13.5 g to 15.6 g).