Experiences of deliberate practice orientated psychological skills training for cancer care staff: Barriers and facilitators to learning and implementation in practice

This study explored participant-reported facilitators and barriers to learning and implementation from a 2-day training in psychological assessment and intervention skills for cancer staff, involving deliberate practice and supervision. Twenty-six semi-structured interviews were analysed using thematic analysis leading to four meta-themes: perceived practicality of training, impact of training: practice and its effects, implementation transfer processes and supervision engagement. Analysis identified a learning process to implementation: observation and practice of techniques during training facilitated participant learning; personal use and relevance of training content encouraged reflection, which enabled selection of appropriate tools for clinical practice; gains in commitment and confidence to use techniques supported participants to adapt clinical consultations, and supervision further facilitated implementation. Changing practice increased confidence, sense of achievement and engagement with participants' own wellbeing. Interactive training, deliberate practice and continuous learning were facilitators to implementation whilst time constraint and low confidence in using techniques in remote consultations were barriers.

Association of admission serum sodium and outcomes following out-of-hospital cardiac arrest

BACKGROUND

The prognostic association between dysnatremia and outcomes in out-of-hospital cardiac arrest (OHCA) is not well understood. Given hypernatremia is associated with poor outcomes in critical illness and hyponatremia may exacerbate cerebral edema, we hypothesized that dysnatremia on OHCA hospital admission would be associated with worse neurological outcomes.

METHODS

We studied adults (≥19 years) with non-traumatic OHCA between 2009 and 2016 who were enrolled in the British Columbia Cardiac Arrest Registry and survived to hospital admission at 2 quaternary urban hospitals. We stratified cases by admission serum sodium into hyponatremic (<135 mmol/L), normonatremic (135-145 mmol/L), and hypernatremic (>145 mmol/L) groups. We used logistic regression models, adjusted for age, sex, shockable rhythm, admission serum lactate, and witnessed arrest, to estimate the association between admission sodium and favorable neurological outcome (cerebral performance category 1-2 or modified Rankin scale 0-3).

RESULTS

Of 414 included patients, 63 were hyponatremic, 330 normonatremic, and 21 hypernatremic. In each respective group, 21 (33.3%), 159 (48.2%), and 3 (14.3%) experienced good neurological outcomes. In univariable models, hyponatremia (OR 0.53, 95% CI 0.30-0.93) and hypernatremia (OR 0.19, 95% CI 0.05-0.65) were associated with lower odds of good neurological outcomes compared to the normonatremia group. After adjustment, only hypernatremia was associated with lower odds of good neurological outcomes (OR 0.22, 95% CI 0.05-0.98).

CONCLUSIONS

Hypernatremia at admission was independently associated with decreased probability of good neurological outcomes at discharge post-OHCA. Future studies should focus on elucidating the pathophysiology of dysnatremia following OHCA.

Outcomes of psychological support skills training for cancer care staff: Skill acquisition, work engagement, mental wellbeing and burnout

OBJECTIVE

Psychological support skills training has the potential to improve both the ability of cancer staff to help their patients, and staff wellbeing. However, few recent studies have assessed both these outcomes or incorporated current developments in psychological skills training, such as deliberate practice, which includes the use of iterative, corrective feedback to identify and improve individualised skill deficits. No studies have evaluated the contribution that psychological skills training could make to cancer care staff wellbeing and expertise in the wake of the COVID-19 pandemic. This study aimed to evaluate staff skill acquisition and work-related wellbeing following psychological support skills training that applied deliberate practice principles.

METHOD

A 2-day training and monthly supervision was offered to 145 cancer care staff that focused on brief assessment and intervention skills for patients experiencing mental health problems after cancer diagnosis and treatment. Deliberate practice principles were used to focus training on skills practice and feedback, over technique description. Self-reported ability to perform key skills taught, staff mental wellbeing, work engagement, and burnout were assessed at baseline, 3-month and 8-month follow-up.

RESULTS

Significant improvements in skills, mental wellbeing, burnout and work engagement were reported at 8-month follow-up. Full engagement in both training sessions was predicted by poorer baseline mental wellbeing, more positive evaluation of initial training, supervision attendance, and shorter follow-up.

CONCLUSION

A 2-day psychological support skills training using deliberate practice principles may support improvement in staff skill, mental wellbeing, burnout and work engagement.

Access to Heart Failure Services in Canada: Findings of the Heart and Stroke National Heart Failure Resources and Services Inventory

BACKGROUND

The rising incidence of heart failure (HF) in Canada necessitates commensurate resources dedicated to its management. Several health system partners launched an HF Action Plan to understand the current state of HF care in Canada and address inequities in access and resources.

METHODS

A national Heart Failure Resources and Services Inventory (HF-RaSI) was conducted from 2020 to 2021 of all 629 acute care hospitals and 20 urgent care centres in Canada. The HF-RaSI consisted of 44 questions on available resources, service,s and processes across acute care hospitals and related ambulatory settings.

RESULTS

HF-RaSIs were completed by 501 acute care hospitals and urgent care centres, representing 94.7% of all HF hospitalisations across Canada. Only 12.2% of HF care was provided by hospitals with HF expertise and resources, and 50.9% of HF admissions were in centres with minimal outpatient or inpatient HF capabilities. Across all Canadian hospitals, 28.7% did not have access to B-type natriuretic peptide testing, and only 48.1% had access to on-site echocardiography. Designated HF medical directors were present at 21.6% of sites (108), and 16.2% sites (81) had dedicated inpatient interdisciplinary HF teams. Among all of the sites, 28.1% (141) were HF clinics, and of those, 40.4% (57) had average wait times from referral to first appointment of more than 2 weeks.

CONCLUSIONS

Significant gaps and geographic variation in delivery and access to HF services exist in Canada. This study highlights the need for provincial and national health systems changes and quality improvement initiatives to ensure equitable access to the appropriate evidence-based HF care.

The association between the Multiple Sclerosis Screening Questionnaire and objective measures of cognition: a systematic literature review and meta-analysis

INTRODUCTION

The Multiple Sclerosis Screening Questionnaire (MSNQ) is a self-report measure used to assess cognitive difficulties in people with Multiple Sclerosis (PwMS). The aim of this systematic review was to determine the associations between the MSNQ and: objective measures of cognition, measures of mood, and quality of life measures.

METHOD

A comprehensive search was done across three databases (PsycINFO, MEDLINE, and CINAHL). A total of 15 studies, including 1992 participants, were selected for final inclusion. Meta-analyses were conducted to determine the pooled effect size of associations. Where data were not available for meta-analyses, a narrative synthesis approach was taken.

RESULTS

Significant, but small (r = -0.17), associations were found between the MSNQ and objective measures of cognition. Significant, moderate associations (r = 0.47) were found between the MSNQ and measures of mood.

CONCLUSIONS

The small association between the MSNQ and objective measures of cognition shows that the measures do not converge well. However, their divergence may be important to map the broad construct of "cognitive ability" more fully. Limitations include a lack of reporting of non-significant effect sizes in individual studies. Clinical implications include the potential for the MSNQ to be used beyond being solely a proxy measure for objective cognition. Future research should investigate the associations between the informant version of the MSNQ and objective measures.

Reperfusion Delays and Outcomes Among Patients With ST-Segment-Elevation Myocardial Infarction With and Without Cardiogenic Shock

BACKGROUND

Mortality remains high in patients with ST-segment-elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS), and early reperfusion has been shown to improve outcomes. We analyzed the association between first medical contact (FMC)-to-percutaneous coronary angiography time with mortality and major adverse cardiovascular events among patients with STEMI with and without CS.

METHODS

We performed a retrospective analysis of the Vancouver Coastal Health Authority STEMI registry, including all patients with STEMI who received primary percutaneous coronary angiography between January 1, 2010, and December 31, 2020, and stratified them by presence or absence of CS at hospital arrival. The primary outcome was in-hospital mortality, the secondary outcome was in-hospital major adverse cardiovascular events, defined as a composite of the first occurrence of mortality, cardiac arrest, heart failure, intracerebral hemorrhage, cerebrovascular accident, or reinfarction. Mixed effects logistic regression with restricted cubic splines was used to estimate the relationships between FMC-to-device time and the outcomes in the CS and non-CS groups.

RESULTS

2929 patients were included, 9.4% (n=275) had CS. Median FMC-to-device time was 113.5 (interquartile range, 93.0-145.0) and 103.0 (interquartile range, 85.0-130.0) minutes for patients with CS and without CS, respectively. More patients with CS had FMC-to-device times above guideline recommendations (76.6% versus 54.1%, P<0.001). Between 60 and 90 minutes, for each 10-minute increase in FMC-to-device time, absolute mortality for patients with CS increased by 4% to 7%, whereas for patients without CS, it increased by <0.5%.

CONCLUSIONS

Among patients with STEMI undergoing primary percutaneous coronary angiography, reperfusion delays among patients with CS are associated with significantly worse outcomes. Strategies to reduce FMC-to-device times for patients with STEMI presenting with CS are required.

Defining the gap in heart failure treatment in patients with cardiac implantable electronic devices

BACKGROUND

The use of guideline-directed medical therapy (GDMT) is poorly described in patients with heart failure and reduced ejection fraction (HFrEF) with cardiac resynchronization therapy (CRT) and/or implantable cardioverter defibrillators (ICDs).

OBJECTIVE

To define the eligibility, uptake, dose, contraindications, and barriers to uptake of contemporary medical therapy in this population.

METHODS

Retrospective analysis of consecutive adults with ICD and/or CRT attending two Canadian tertiary centre device clinics between 1 March and 31 May 2021.

RESULTS

From 1005 device clinic consultations, 227 (22.6%) patients with HFrEF and CRT and/or ICD were included. GDMT eligibility was high: beta-blockers (99.6%), mineralocorticoid receptor antagonists (MRA) (89.0%), angiotensin receptor-neprilysin inhibitors (ARNI) (84.6%), and sodium-glucose cotransporter-2 inhibitors (SGLT2I) (87.7%). Contraindications were rare: beta-blockers (0.4%), MRA (11.0%), ARNI (15.4%), and SGLT2I (12.3%). Uptake of GDMT was high for beta-blockers (97.4%) but low for other medications: MRA (63.0%), ARNI (46.7%), SGLT2I (22.9%). Except for SGLT2I (84.6%) and beta-blockers (57.9%), less than one-half of patients were prescribed target-doses of MRA (10.5%), and ARNI (47.7%). Of the visits, GDMT was already optimal in 16%, electrophysiologists acted in 33% (21% prescribed, 7% ordered investigations, 5% referred to heart function services), and in the remaining visits, optimization was either deferred to another cardiologist (20%) or no plan was mentioned (25%), besides other reasons (4%).

CONCLUSION

Despite broad eligibility for GDMT in patients with HFrEF and ICD/CRT, significant gaps in prescription and titration exist. Our results highlight the need to embed quality assurance initiatives in cardiac device clinics to improve HFrEF care.

Specificity and sensitivity of the social communication questionnaire lifetime screening tool for autism spectrum disorder in a UK CAMHS service

INTRODUCTION

The Social Communication Questionnaire is used to identify children and young people (CYP) who may require formal ASD assessment. However, there is a paucity of research on its utility in Children and Adolescent Mental Health Services. This evaluation aimed to determine the sensitivity and specificity of the Social Communication Questionnaire (SCQ) in a UK, Midlands CAMHS service.

METHOD

Forty young people (mean age 13.75 years) were screened using the caregiver reported SCQ before completing 'gold standard' assessment.

RESULTS

The SCQ had a sensitivity of 80% and a specificity of 25.7%. ROC curve analysis indicated low diagnostic accuracy. Differences in predictive accuracy of SCQ and diagnostic standard were statistically significant (p < 0.0001).

CONCLUSION

This evaluation builds on previous research suggesting that the SCQ may not be an efficient screening tool in CAMHS settings.

Examining anxiety and depression in haematology cancer patients in ongoing treatment and under watchful waiting: A systematic review and meta-analysis

INTRODUCTION

The present review aimed to establish prevalence rates of anxiety and depression in adults with haematology cancer, with a focus on the differences between patients under treatment and patients under watchful waiting.

METHOD

Five databases (Scopus, Medline, PsycINFO, EThOS, CINAHL) were searched throughout June 2021. Key search terms included haematology cancer, anxiety, depression, in treatment and watchful waiting. Study and sample characteristics, prevalence rates and mean self-reported scores of anxiety and depression data were extracted.

RESULTS

A total of 18 eligible papers were included in the review. Quality appraisal indicated papers were of adequate standard. Depression data from 2720 participants (14.5% under watchful waiting) and anxiety data from 2520 participants (15.9% under watchful waiting) were analysed through subgroup meta-analyses. The prevalence of anxiety was 34% amongst adults receiving treatment and 24.5% amongst those under watchful waiting. The prevalence of depression amongst adults receiving treatment was 31.3%, significantly higher than 16.1% of adults under watchful waiting.

CONCLUSION

Overall, adults with haematology cancer were at greater risk of experiencing anxiety and depression than the general population, with greatest risk in those under treatment. The findings indicate the need for future research to examine availability and effectiveness of targeted psychological interventions.

A systematic review of the barriers and facilitators to adherence to mindfulness‐based cognitive therapy for those with chronic conditions

PURPOSE

Mindfulness-Based Cognitive Therapy (MBCT) can improve the lives of those with a chronic condition and psychological distress, however, high drop-out rates limit benefits. MBCT might be a candidate treatment for this population if nonadherence can be overcome. This review explores the existing literature on the barriers and facilitators to adherence to MBCT for those with chronic conditions.

METHOD

Databases MEDLINE, PsycINFO, CINAHL and Scopus were searched between 28^th May and 11th June 2021. We included empirical papers that identified barriers and/or facilitators to MBCT adherence in patients with chronic conditions-excluding non-English and grey literature. Papers were screened and duplicates removed. Extracted data included: setting, design, aim, sample-size, population and identified barriers/facilitators to MBCT adherence. The Mixed Methods Appraisal Tool (MMAT) was adapted and used to appraise the quality of studies RESULTS: Twenty papers were eligible for review. Synthesis identified six themes (in prevalence order): (1) Practical Factors (e.g., time and other commitments), (2) Motivation (e.g., change-readiness), (3) Patient clinical and demographic characteristics (e.g., current physical health), (4) Connection with Others (facilitators and group members), (5) Credibility (perception of the intervention) and (6) Content difficulty (intervention accessibility). Findings highlight potential adaptations to implementation (e.g., clear treatment rationale, preference matching, and eliciting and responding to individual concerns or obstructive assumptions) that could address barriers and harness facilitators.

CONCLUSION

This review contributes a higher order understanding of factors that may support/obstruct client adherence to MBCT with implications for future implementation in research and practice. Future research should prioritize open exploration of barriers/facilitators.

The Development and Validation of the Comprehensive Assessment of Acceptance and Commitment Therapy Processes (CompACT)—Malay Version

Objectives: psychological flexibility is a crucial construct highly correlated with psychological wellness. There is a need for a tool to measure psychological flexibility in order to accurately ascertain the effects of treatment. The existing industry standard, the Acceptance and Action Questionnaire-II (AAQ-II), has issues with conflating psychological flexibility with distress; moreover, it does not cover the hexaflexes. The 23-item CompACT was designed to surmount these limitations. Methods: the classical test theory (CTT) and Rasch measurement theory (RMT) were used to check the validity and reliability of the Malay version of the CompACT Scale. Cronbach’s α, McDonald’s Ω, and greatest lower bound were used to measure internal consistency. A Pearson’s correlation test was used to measure test–retest reliability of the Malay versus the original English version. For validity, convergent validity was established by using the Malay AAQ-7 Scale. The dimensionality of the Malay version of the CompACT Scale was explored using exploratory factor analysis. For the RMT, weighted fit statistics (infit) and outlier sensitive fit statistic (outfit) mean square (MnSq) values were used at the item level, while item and person separation reliability values and item and person separation indices were applied at the scale level. Results: the internal consistency measures, including Cronbach α and McDonald’s Ω, passed the suggested cutoff points. Convergent validity with the AAQ-II was 0.693. The quality of the Malay version of the CompACT Scale was also satisfactory, as all item and person reliability values and indices exceeded the suggested cut-off points. Conclusions: the Malay CompACT is a psychometrically sound instrument to assess psychological flexibility in both clinical and research settings.

Care and Outcomes of ST-Segment Elevation Myocardial Infarction Across Multiple COVID-19 Waves

BACKGROUND

There are concerns of delays in ST-segment elevation myocardial infarction (STEMI) care during the COVID-19 pandemic. It is unclear whether the care and outcomes of STEMI patients differ between COVID-19 waves and compared with historical periods.

METHODS

Consecutive patients in the Vancouver Coastal Health Authority STEMI database were included to compare care during 3 distinct waves of the COVID-19 pandemic (9 months; March 2020 to January 2021) with an historical non-COVID-19 cohort. We compared STEMI incidence, baseline characteristics, and outcomes between groups. We also examined time from first medical contact (FMC) to reperfusion, symptom to FMC, and FMC to STEMI diagnosis, as well as predictors of delays.

RESULTS

The incidence of STEMI was similar during COVID-19 (n = 305; mean 0.93/day) and before COVID-19 (n = 949; 0.97/day; P = 0.80). The COVID-19 cohort showed significant delay in FMC-to-reperfusion (median 116 min vs 102 min; P < 0.001) and FMC-to-STEMI diagnosis (median 17 mins vs 11 min; P < 0.001). Delays in FMC-to-device times worsened across the 3 COVID-19 waves (FMC-to-device time ≤ 90 min in wave 1: 32.9%; in wave 2: 25.6%; in wave 3: 16.3%; P = 0.045 [47.5% before COVID-19; P < 0.001]). There were no significant predictors of delay were unique to the COVID-19 cohort.

CONCLUSIONS

This study demonstrates delays in reperfusion during the COVID-19 pandemic compared with the historical control, with delays increasing during subsequent waves within the pandemic. It is critical to further understand these care gaps to improve STEMI care for future waves of the current and future pandemics.

"I don't want to take buprenorphine for the rest of my life": Acceptance and Commitment Therapy for a Client Struggling to Reduce Low-Dose Buprenorphine (a Hermeneutic Single-Case Efficacy Design)

The misuse of substances is often maintained by both physical and psychological factors. Opioid-substitution medications manage physical aspects of addiction; however, difficulties with emotional regulation and avoidance perpetuate continued substance misuse. In the UK, individuals who misuse substances are often excluded from mental health services, meaning these underlying difficulties are not addressed. Acceptance and Commitment Therapy (ACT) seeks to reduce emotional avoidance. A hermeneutic single-case efficacy design was used to evaluate the effects of ACT within drugs and alcohol service. Quantitative and qualitative data was critically analysed to understand factors involved in identified changes. Analysis recognised the client progressed towards two of three of their goals, related to motivation and anxiety. Their psychological flexibility also increased. ACT processes played a key role in this; however, the therapeutic relationship and psychopharmacological factors were also noted. Study limitations and clinical and research implications are discussed.

Impact of oral soluble guanylate cyclase stimulators in heart failure: A systematic review and Meta-analysis of randomized controlled trials

BACKGROUND

Soluble guanylate cyclase (sGC) stimulators are a novel class of medications with emerging role in heart failure (HF). The aim of this study is to evaluate the efficacy and safety of oral sGC stimulators in patients with HF with reduced and preserved ejection fraction (HFrEF and HFpEF) by pooling data from all available randomized control trials (RCT).

METHODS

A comprehensive search of electronic databases from 2000-2020 was performed. Seven RCTs, three HFrEF and four HFpEF studies, were identified. The follow-up duration ranged from 1 month to a median of 10.8 months. A random-effects meta-analysis was conducted to summarize the studies.

RESULTS

The study population included 7190 patients: 5707 HFrEF and 1483 HFpEF patients. In HFrEF, oral sGC stimulators reduced the composite incidence of HF hospitalization and cardiovascular death (hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.78-0.97; I² = 0%), primarily driven by lower HF hospitalization (HR 0.88, 95% CI 0.78-0.99; I² = 0%). There was no significant reduction in all-cause death in HFrEF (HR 0.95, 95% CI 0.83-1.09; I² = 0%). In HFpEF, there were no improvements in Kansas City Cardiomyopathy Questionnaire clinical summary scores (mean difference 0.81, 95% CI -2.16-3.77; I² = 72%) or 6-minute walk distance (mean difference 3.34 meters, 95% CI -7.86-14.54; I² = 28%). There was no difference in all-cause mortality in HFpEF (HR 1.94, 95% CI 0.92-4.09; I² = 0%). Overall, oral sGC stimulators had low medication-related serious adverse events.

CONCLUSION

Oral sGC stimulators are well tolerated in HF and reduce the incidence of HF hospitalization but not cardiovascular death among patients with HFrEF. However, there are no apparent benefits in HFpEF.

COVID-19 DIAGNOSIS BY POINT OF CARE LUNG ULTRASOUND: A NOVEL DEEP LEARNING ARTIFICIAL INTELLIGENCE METHOD

BACKGROUND

METHODS AND RESULTS

CONCLUSION

The predictive value of patient, therapist, and in-session ratings of motivational factors early in remote cognitive behavioural therapy for severe health anxiety

OBJECTIVES

Remote psychotherapy and the prevalence of Severe Health Anxiety (SHA) are both growing as a result of the COVID-19 pandemic. Remotely delivered Cognitive Behavioural Therapy (rCBT) for SHA is evidenced as effective, but many who seek help do not benefit. Motivational processes can influence outcomes, but it is unclear what assessment methods offer the best clinical utility in rCBT for SHA.

DESIGN

This study compared the predictive validity of patient, therapist and in-session ratings of motivational factors taken at session two of rCBT for SHA among high healthcare users experiencing multimorbidity.

METHODS

Motivational factors were assessed for 56 participants who attended at least two sessions of CBT for SHA delivered via video-conferencing or telephone. Following session two, therapists and patients completed online assessments of patient motivation. Two trained observers also rated motivational factors and therapeutic alliance from in-session interactions using session two recordings and transcripts. Multilevel modelling was used to predict health anxiety and a range of secondary health outcomes from motivation assessments.

RESULTS

Where patients were more actively engaged in discussion of positive changes during session two, greater outcome improvements ensued in health anxiety and all secondary outcomes. Conversely, larger proportions of session two spent describing problems predicted poorer outcomes. Therapist and patient assessments of motivation did not predict health anxiety, but therapist assessments of client confidence and motivation predicted all secondary outcomes.

CONCLUSIONS

Motivation remains an important process in CBT when delivered remotely, and motivational factors may predict outcomes more consistently from in-session interactions, compared to self-reports.

Compassion-focused therapies for self-esteem: A systematic review and meta-analysis

PURPOSE

To identify whether compassion-focused therapy (CFT) or compassion-based interventions are effective in improving self-esteem.

METHODS

Databases (CINAHL, MEDLINE, and PsycINFO) were searched, along with OpenGrey literature. Experts were also contacted and handsearching of reference lists and citing articles undertaken. To be eligible, papers had to include an intervention identified as being compassion-based and mention 'self-esteem' as a variable or outcome. Papers were quality appraised using the Mixed Methods Appraisal Tool. Data were analysed using a random-effects meta-analysis model, with sensitivity analysis conducted in relation to the quality of studies.

RESULTS

Ten eligible papers were identified. Within-group analysis of data from eight studies demonstrated a medium, significant overall effect size (g = 0.56, 95% CI [0.19-0.93], z = 3.54, p < .001), which increased slightly and remained significant (g = 0.61, 95% CI [0.05-1.17], z = 2.82, p = .005) when the lowest quality studies were removed.

CONCLUSIONS

Compassion-focused therapy or compassion-based interventions may be effective in improving self-esteem. However, there is large clinical and methodological heterogeneity amongst studies making further conclusions difficult.

PRACTITIONER POINTS

CFT/compassion-based interventions appear to be effective in improving self-esteem. Transdiagnostic concepts (such as low self-esteem and compassion-focused therapy) should be considered in supporting people with their mental health.

Factors associated with psychological distress for couples facing head and neck cancer: A systematic literature review

OBJECTIVES

Cancer patients in supportive relationships display improved health and survival outcomes. Identifying factors that might respond to intervention for Head and Neck Cancer (HNC) dyads is important as HNC patients and their partners experience heightened distress. This article systematically reviewed and evaluated the research findings and methodological quality of studies which identified factors influencing psychological distress for couples facing HNC.

METHODS

PsycINFO, Medline, and CINAHL were searched. Studies were included if they used validated psychological distress measures and quantitative data collection methods. Eleven studies satisfied inclusion criteria.

RESULTS

Studies identified factors associated with the psychological distress experienced by couples facing HNC, with substantial effect size variation. These factors included clinical, sociodemographic, relational, and psychological variables. Factors associated with increased psychological distress included disease burden, reduced social contact, perception of reduced relationship quality, and less adaptive/assimilative coping although the effect sizes displayed considerable heterogeneity. Overall, studies possessed good methodological quality but generally could have been improved by minimising the risk of non-response bias and fully reporting relational characteristics.

CONCLUSIONS

The implications of these results for clinical practice and future research are discussed. Further research is recommended to report effect sizes more consistently for both dyad members to gain greater insight into couple-level distress and to perform moderator analyses to identify which variables influence the magnitude of psychological distress.

Impact of targeted pulmonary arterial hypertension therapy in patients with combined post- and precapillary pulmonary hypertension

BACKGROUND

Combined post- and precapillary pulmonary hypertension (CpcPH) portends poor outcomes in pulmonary hypertension related to left heart disease (PH-LHD). While recent evidence does not support the use of targeted pulmonary arterial hypertension (PAH) therapy in PH-LHD, there is a lack of clinical data on their use in CpcPH. We evaluated the outcomes in patients with CpcPH treated with PAH therapies.

METHODS

Retrospectively, 50 patients meeting hemodynamic criteria of CpcPH and started on PAH-targeted drugs were identified. Fifty age- and gender-matched PAH patients were chosen as controls. We evaluated the change in 6-minute walk distance, World Health Organization functional class (FC), tricuspid annular plane systolic excursion, BNP or NT-proBNP, and pulmonary artery systolic pressure at 3, 6, 12, and 24 months of follow-up.

RESULTS

After adjusting for age and gender, there was no improvement in World Health Organization FC in CpcPH over 2 years (odds ratio of change to FC I/II 1.01, 95% CI: 0.98-1.04). There was no significant improvement in 6-minute walk distance (β coefficient 0.21, 95% CI: -0.98 to 1.4), reduction in BNP/NT-proBNP (β coefficient -12.16, 95% CI: -30.68 to 6.37), increase in tricuspid annular plane systolic excursion (β coefficient 0.074, 95% CI: 0.010-0.139), or decrease in pulmonary artery systolic pressure (0.996, 95% CI: 0.991-1.011) in CpcPH with therapy. There was higher mortality in CpcPH compared to PAH on treatment (24% vs 4%, P = .003).

CONCLUSIONS

There were no improvements in symptoms, exercise capacity, or echocardiographic parameters with PAH-targeted therapy in CpcPH. Further studies into potential treatments benefiting this population are needed.

A brief acceptance and commitment intervention for work-related stress and burnout amongst frontline homelessness staff: A single case experimental design series

PURPOSE

Recent intervention research for burnout amongst those working in health and social care contexts has found acceptance and commitment therapy (ACT) interventions to be of use but has provided less clarity on the role of psychological flexibility (a key ACT construct). This study further evaluated the usefulness of ACT for burnout and work-engagement and assessed the role of psychological flexibility in contributing to therapeutic change.

PROCEDURE

A nonconcurrent multiple-baseline across-participants single-case experimental design was used. Four participants were recruited from a homelessness organization in the East Midlands, England. The ACT-intervention was split into three modules to reflect the three aspects of the ACT triflex, and the sequence of delivery was randomized for each participant in order to test the relationship between these aspects.

FINDINGS

Support was found for the ACT intervention reducing exhaustion and increasing work-engagement. Psychological Flexibility increased in all participants and was temporally related to increases in other outcome variables in some instances. Delivery of the intervention focussed on any given aspect of the ACT triflex could increase different domains of psychological flexibility.

IMPLICATIONS

This study adds to the growing body of research in favour of ACT interventions for burnout and adds to the understanding of psychological flexibility as a mediating variable.

Cardiogenic shock teams and centres: a contemporary review of multidisciplinary care for cardiogenic shock

Cardiogenic shock (CS) portends high morbidity and mortality in the contemporary era. Despite advances in temporary mechanical circulatory supports (MCS), their routine use in CS to improve outcomes has not been established. Delays in diagnosis and timely delivery of care, disparities in accessing adjunct therapies such revascularization or MCS, and lack of a systematic approach to care of CS contribute to the poor outcomes observed in CS patients. There is growing interest for developing a standardized multidisciplinary team-based approach in the management of CS. Recent prospective studies have shown feasibility of CS teams in improving survival across a spectrum of CS presentations. Herein, we will review the rationale for CS teams focusing on evidence supporting its use in streamlining care, optimizing revascularization strategies, and patient identification and MCS selection. The proposed structure and flow of CS teams will be outlined. An in-depth analysis of four recent studies demonstrating improved outcomes with CS teams is presented. Finally, we will explore potential implementation hurdles and future directions in refining and widespread implementation of dedicated cross-specialty CS teams.

Predicting outcomes and sudden gains from initial in-session interactions during remote cognitive-behavioural therapy for severe health anxiety

There has been a dramatic increase in remote psychotherapy since the onset of the COVID-19 crisis. There is also expected to be an increase in mental health problems in the wake of the COVID-19 pandemic. An increase in severe health anxiety (SHA) is particularly anticipated, for which cognitive-behavioural therapy (CBT) is a frontline treatment. However, it is unclear what interaction types are associated with outcome-improvement in remote-CBT (rCBT) for SHA. This study aimed to identify interaction types that predict outcomes and sudden gains in rCBT for SHA using initial therapy session content. Forty-eight participants in rCBT for SHA had interactions at their first sessions categorized and rated in terms of patient activation: an individual's confidence and ability to manage their health. Multilevel modelling assessed whether early interaction types predicted session-by-session wellbeing. For participants experiencing sudden gains (n = 12) interactions at the session directly prior to the gain were similarly categorized and rated. The scores were then compared with ratings for the preceding session. A smaller proportion of early sessions was taken up with problem descriptions among those with greater outcome improvements. There was also a significant reduction in the proportion of the session spent describing problems in the session directly prior to a sudden gain, as compared with the previous session. Conversely, clients with better outcomes made more positive evaluations of themselves and therapy, noticed more positive changes and made more contributions to structuring interactions at initial sessions. Specific early interaction types predict session-by-session outcomes and precede sudden gains in rCBT for SHA.

Factors influencing the transition experience of carers for persons with dementia, when the person with dementia moves into residential care: systematic review and meta-synthesis

Aims: To understand factors influencing the experience of carers for people with dementia, when that person moves from living in the community to living in residential care. Specifically, we aimed to identify facilitators and inhibitors of carer adjustment during this transition.Method: A systematic search of CINAHL, EMBASE, PubMed, and PsycINFO databases was conducted. Nine qualitative articles published between 2001 and 2017, based on the experiences of 141 carers, were included. Thematic analysis was applied to the data, with the concepts of transition inhibitors and facilitators being used to structure the analytic process.Results: Analysis produced five themes, representing factors that could affect carer experiences of the focal transition-process: modifying the difficulty of this process according to their presence or absence. The themes were (1) Connection, pertaining to the carer feeling connected to the person with dementia and professionals during this transition; (2) Informed & Informing, relating to exchange of information between the carer and facility staff or health professionals; (3) The facility: welcoming & skilful, dealing with carer perceptions of the facility and their confidence in the staff; (4) It's What You Make of It, discussing the meaning the carer made of the admission and the impact this had; and (5) Sharing Responsibility, addressing how carers were affected by the perceived sharing of responsibility for care-provision.Conclusions: A supportive network has a significant role to play in facilitating this transition for carers. However, further research into what carers would find useful during this time is needed.

Reducing dropout in acceptance and commitment therapy, mindfulness-based cognitive therapy, and problem-solving therapy for chronic pain and cancer patients using motivational interviewing

OBJECTIVE

Acceptance and commitment therapy, mindfulness-based cognitive therapy, and problem-solving therapy are types of cognitive-behavioural therapy (CBT) group that improve physical and mental health in chronic pain or cancer. However, dropout is high due to group demands alongside physical impairments. Motivational interviewing (MI) is a well-evidenced means of enhancing treatment adherence. Few studies have investigated MI as an adjunct to CBT in cancer or chronic pain, and none have established the minimum MI duration required for adherence improvement. This study evaluated minimal-duration MI to improve adherence in three CBT group types for cancer and chronic pain.

METHODS

In a cohort study of 99 cancer and chronic pain patients, 47 were given a 10- to 15-min structured MI telephone intervention (MI-call) after the first session. The remaining 52 received a CBT group without MI (no-MI).

RESULTS

Odds of completing group CBTs were five times greater for patients in the MI-call cohort versus no-MI. Effects remained when controlling for age, gender, diagnosis, group type, and baseline quality of life. The MI-call cohort attended one extra session per patient compared to no-MI, controlling for age, gender, and diagnosis.

CONCLUSIONS

A brief MI telephone intervention may improve adherence to group CBTs in cancer and chronic pain.

PRACTITIONER POINTS

A brief motivational interviewing (MI) telephone intervention may reduce dropout from group cognitive-behavioural therapies (CBTs) for cancer and chronic pain patients when administered after the first group session in routine care. Recipients of this intervention were five times more likely to complete a group CBT programme than those who did not receive it. Therefore, a minimal-dose MI intervention can have clinically important effects on dropout in group CBTs for patients with long-term conditions. It is unclear whether this intervention would also result in greater outcome improvements.

The Efficacy of Cognitive Behavioral Therapy for Adults With ADHD: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Objective: To systematically review the literature on published randomized controlled trials (RCTs) of cognitive behavioral therapy (CBT) for adult ADHD and to establish the effectiveness of CBT in reducing ADHD symptoms. Method: A systematic review of nine RCTs and two subsequent meta-analyses of eight of the studies were conducted. Results: Just nine studies were identified, of generally good quality but with some limitations. Four trials (total N = 160) compared CBT with waiting list controls, and three trials (total N = 191) compared CBT with appropriate active control groups. Meta-analyses showed that CBT was superior to waiting list with a moderate to large effect size (standardized mean difference [SMD] = 0.76, 95% confidence interval [CI] [0.21, 1.31], p = .006) and superior to active control groups with a small to moderate effect size (SMD = 0.43, 95% CI [0.14, 0.71], p = .004). Conclusion: These results give support to the efficacy of CBT in reducing symptoms of ADHD post-intervention.

Experiences of adjustment to secondary progressive multiple sclerosis: a meta-ethnographic systematic review

PURPOSE

To provide an overview of the experiences and needs of patients adjusting to life after receiving a diagnosis of secondary progressive multiple sclerosis (SPMS).

METHOD

We conducted a meta-ethnographic synthesis of qualitative studies on the experiences of transition to SPMS, based on a systematic literature search of CINAHL, PsycINFO, Embase, MEDLINE, and Web of Science. Identified studies were quality-appraised using a critical appraisal checklist, and individual findings synthesised inductively.

RESULTS

The synthesis included 12 articles with 144 people with SPMS. Adjusting to SPMS transition encompassed a variety of reactions and coping strategies. Successful adjustment was associated with accepting and adapting coping strategies, and availability of social support and relationships. Clinical services increased uncertainty around adjustment where patients felt clinicians were not transparent with them about their changing diagnosis.

CONCLUSIONS

People adjust to SPMS in different ways, with the success of adjustment influenced by a patient's primary coping mechanism. Coping mechanisms are determined by pre-existing individual differences, alongside engagement with, and quality of, social support networks and activities. Services should ensure that people are provided with informational support about their illness progression, and emotional support concerning coping strategies, social networks, and physical activity, as these are key determinants of successful adjustment.IMPLICATIONS FOR REHABILITATIONAdjusting to secondary progressive multiple sclerosis is a difficult and stressful time for patients.Coping strategies patients use, their support network and their activity levels are key determinants of successful adjustment.Clinicians should be open with patients about their assessment of their changing diagnosis, rather than trying to avoid upsetting the patient by withholding information.Clinical services should be proactive in supporting patients during adjustment with learning positive coping strategies, and maintaining or increasing social relationships and activity levels.

Association of left anterior descending artery involvement on clinical outcomes among patients with STEMI presenting with and without out-of-hospital cardiac arrest

Background

ST-segment elevation myocardial infarction (STEMI) outcomes are influenced by the location of the culprit vessel with worse outcomes portended with a left anterior descending (LAD) culprit lesion. However, relatively little is known about the independent association of LAD involvement with clinical outcomes of patients with STEMI with and without out-of-hospital cardiac arrest (OHCA).

Methods

We identified 91 patients with and 929 without a preceding OHCA within the Vancouver Coastal Health Authority who presented with an acute STEMI and underwent primary percutaneous coronary intervention between 26 June 2007 and 31 March 2016.

Results

Patients with STEMI with OHCA had higher rates of in-hospital cardiac arrest (43.3% vs 8.3%, p<0.001), heart failure (50.5% vs 11.3%, p<0.001), cardiogenic shock (49.5% vs 5.7%, p<0.001), mortality (35.2% vs 3.3%, p<0.001) and reduced left ventricular ejection fraction (LVEF; 42.9% vs 47.3%, p<0.001) compared with those without OHCA. Among patients without OHCA, LAD involvement was associated with increased heart failure (18.1% vs 5.2%, p<0.001), in-hospital cardiac arrest (10.7% vs 6.2%, p<0.014), cardiogenic shock (8.4% vs 3.3%, p<0.001), reduced LVEF (43.0% vs 51.2%, p<0.001) and mortality (5.2% vs 1.3%, p=0.003) compared with patients without LAD involvement. With the exception of LVEF, these associations were not seen among patients with STEMI with OHCA and an LAD culprit. The presence of an LAD culprit was not independently associated with increased hospital mortality among patients with OHCA after adjusting for potential confounding factors.

Conclusion

Our study has demonstrated a differential impact of LAD involvement on clinical outcomes among patients with STEMI who present with and without OHCA. Our data highlight the complexity surrounding the prognostication following OHCA complicating STEMI and demonstrate that other mechanisms other than LAD involvement contribute to the high mortality associated with OHCA as a result of STEMI.

Preventing relapse with personalized smart-messaging after cognitive behavioural therapy: A proof-of-concept evaluation

OBJECTIVES

Cognitive behavioural therapy (CBT) can improve symptoms of anxiety and depression, but also reduces the risk of future relapse after therapy completion. However, current CBT relapse prevention methods are resource-intensive and can be limited in clinical practice. This paper investigates a personalized means of reducing relapse using smart-messaging in two settings: research and routine care.

DESIGN

Study 1 presents a cohort study comparing a cohort of smart-messaging users versus non-users. Study 2 presents time series follow-up data from a case series of smart-messaging users from clinical practice.

METHODS

Fifteen of 56 CBT completers who participated in a trial for the treatment of health anxiety wrote advice they would want if in future they were doing well, experiencing early warning signs of relapse, or experiencing full relapse. Following CBT, participants received weekly text-message requests to rate their well-being. Dependent upon their response, participants received tailored advice they had written, appropriate to the well-being level reported after recovery from health anxiety. Smart-messaging was also trialled in a routine practice sample of 14 CBT completers with anxiety and depression.

RESULTS

Across a 12-month follow-up, participants receiving smart-messaging showed greater health improvements than those who did not. Well-being scores showed stability between CBT completion and 6-month follow-up among routine care patients.

CONCLUSIONS

These findings suggest that a low-intensity, personalized relapse prevention method can have a clinical benefit following CBT for common mental health problems.

PRACTITIONER POINTS

Post-treatment outcomes may be improved using personalized smart-messaging to prevent relapse following cognitive behavioural therapy (CBT) for health anxiety. In clinical practice, post-treatment smart-messaging can be well-used by patients and may help maintain stable well-being in the 6 months after CBT ends. This evidence supports the clinical utility of a brief tailored digital intervention, which can be integrated within routine clinical practice with minimal therapist input. Overall, longer-term post-CBT outcomes may be improved by integrating a smart-messaging intervention at the end of therapy.

Behavioural activation treatment for depression in individuals with neurological conditions: a systematic review

OBJECTIVE

To evaluate the effectiveness of behavioural activation interventions for people with neurological conditions with comorbid depression, and explore content and adaptations.

DATA SOURCES

PsycINFO, MEDLINE, CINAHL, AMED, and EMBASE databases were searched on the 19 November 2019. Reference lists of selected full-texts were screened by title.

REVIEW METHODS

We included peer-reviewed studies published in English that used behavioural activation for treatment of depression in adults with a neurological condition. Single-case reports, reviews, and grey literature were excluded. Methodological quality was assessed by two authors independently, and quality was appraised using Critical Appraisal Skills Programme checklists.

RESULTS

From 2714 citations, 10 articles were included comprising 590 participants. Behavioural activation was used to treat depression in people with dementia (n = 4), stroke (n = 3), epilepsy (n = 1), Parkinson's disease (n = 1), and brain injury (n = 1). Sample size ranged from 4 to 105 participants. There were seven randomized controlled studies; however, no studies compared behavioural activation to an alternative psychological therapy. The effect sizes varied between small and large in the studies where effect size could be calculated (d = 0.24-1.7). Methodological quality of the included studies was variable. Intervention components were identifying and engaging in pleasurable activities, psychoeducation, and problem-solving. Adaptations included delivering sessions via telephone, delivering interventions via primary caregivers, and giving psychoeducation to caregivers.

CONCLUSION

The effectiveness of behavioural activation in randomized controlled trials varied from small to large (d = 0.24-1.7) in reducing depression. The content of behavioural activation was comparable to established treatment manuals. Adaptations appeared to support individuals to engage in therapy.

REVIEW REGISTRATION

PROSPERO 2018, CRD42018102604.

Patient activation in psychotherapy interactions: Developing and validating the consultation interactions coding scheme

OBJECTIVE

We describe the development of an instrument aiming to offer interaction-level feedback based on "patient activation": client confidence and perceived ability to manage their health.

METHOD

Twenty-two session-transcripts from cognitive behavioral therapy with high-users of healthcare were analyzed thematically, producing themes describing in-session interactions. Themes were subcategorized using patient activation theory into high and low activation presentations. Two coders new to the process were trained to use this consultation interactions coding scheme (CICS). Inter-rater reliability (IRR), convergent validity, and clinical utility were assessed and illustrated with extreme cases.

RESULTS

Good-to-excellent IRR was achieved. The CICS, therapeutic alliance, and therapist competence were correlated. Client engagement in session-structuring interactions correlated with outcome. The highest CICS scorer showed multiple outcome-improvements, the lowest scorer reported deteriorations.

CONCLUSIONS

This study presents the CICS's psychometric properties and indicates the value of client engagement in session-structuring.

Interventions for reducing levels of burden amongst informal carers of persons with dementia in the community. A systematic review and meta-analysis of randomised controlled trials

Objectives: Caregiver burden can lead to increased stress, depression and health difficulties for caregivers and care-recipients. This systematic review aimed to examine the published evidence, for interventions designed to reduce levels of carer burden, in those caring for a person with dementia. Methods: Three databases were searched (Medline, PsycINFO and CINAHL) for studies reporting on randomised controlled trials of non-pharmacological interventions for dementia-related caregiver burden. Data quality checks were completed for included papers and meta-analysis was performed to estimate the efficacy of individual interventions and different categories of non-pharmacological intervention. Results: Thirty studies were included in the analysis. Seven studies found a significant reduction in carer burden and a pooled effect found that intervening was more effective than treatment as usual (SMD = -0.18, CI = -0.30, -0.05). This result was small, but significant (p = 0.005). Multi-component interventions are more effective than other categories. High heterogeneity means that results should be interpreted with caution. Conclusions: Interventions that significantly reduced levels of burden should be replicated on a larger scale. The relative effectiveness of interventions targeting cognitive appraisals and coping styles suggests that future interventions might be informed by models theorising the role of these processes in carer burden.

Is the Wellness Recovery Action Plan (WRAP) efficacious for improving personal and clinical recovery outcomes? A systematic review and meta-analysis

OBJECTIVE

The Wellness Recovery Action Plan (WRAP) is a structured approach to illness self-management that is widely used within mental health services. This systematic review identifies, appraises, and meta-analyzes quantitative evidence from experimental or quasi-experimental comparison group designs for effects of WRAP on measures reflecting personal recovery and clinical symptomatology.

METHOD

A systematic strategy was used to search 6 electronic reference databases (Medline, CINAHL, EMBASE, PsycINFO, PsycARTICLES, The Cochrane Library) using full-text, keywords, and Medical Subject Headings (MeSh)/Thesaurus headings terms. Unpublished research was identified using the same strategy in the EThOS database. Controlled trials of WRAP were selected and assessed for quality. Meta-analyses were applied to quantitative data to establish the effects of WRAP on outcomes of interest.

RESULTS

Of 253 studies initially identified, 5 quantitative studies (reported in 6 papers) reporting controlled trials were included in the review. Meta-analyses revealed that, relative to inactive control conditions, WRAP was (a) superior for promoting self-perceived recovery outcomes (demonstrating a small-but-significant pooled effect), but (b) not superior for reducing clinical symptomatology-although restriction to randomized-controlled trials revealed 1 small effect favoring WRAP for reducing depression.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Participation in WRAP has positive outcomes for participants, quantifiable using comprehensive measures of self-perceived recovery. Improvements were not sustained over time. Future research could explore this, as well as potential effects of follow-up WRAP sessions. The results support a move to broader measurement of outcomes within mental health, away from a reliance on clinical outcome measures. Recommendations for further research are made. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Using smart-messaging to enhance mindfulness-based cognitive therapy for cancer patients: A mixed methods proof of concept evaluation

Objective

Depression and anxiety lead to reduced treatment adherence, poorer quality of life, and increased care costs amongst cancer patients. Mindfulness‐based cognitive therapy (MBCT) is an effective treatment, but dropout reduces potential benefits. Smart‐message reminders can prevent dropout and improve effectiveness. However, smart‐messaging is untested for MBCT in cancer. This study evaluates smart‐messaging to reduce dropout and improve effectiveness in MBCT for cancer patients with depression or anxiety.

Methods

Fifty‐one cancer patients attending MBCT in a psycho‐oncology service were offered a smart‐messaging intervention, which reminded them of prescribed between‐session activities. Thirty patients accepted smart‐messaging and 21 did not. Assessments of depression and anxiety were taken at baseline, session‐by‐session, and one‐month follow‐up. Logistic regression and multilevel modelling compared the groups on treatment completion and clinical effectiveness. Fifteen post‐treatment patient interviews explored smart‐messaging use.

Results

The odds of programme completion were eight times greater for patients using smart‐messaging compared with non‐users, controlling for age, gender, baseline depression, and baseline anxiety (OR = 7.79, 95% CI 1.75 to 34.58, p = .007). Smart‐messaging users also reported greater improvement in depression over the programme (B = ‐2.33, SEB = .78, p = .004) when controlling for baseline severity, change over time, age, and number of sessions attended. There was no difference between groups in anxiety improvement (B = ‐1.46, SEB = .86, p = .097). In interviews, smart‐messaging was described as a motivating reminder and source of personal connection.

Conclusions

Smart‐messaging may be an easily integrated telehealth intervention to improve MBCT for cancer patients.

Extending the use of routine outcome monitoring: Predicting long-term outcomes in cognitive behavioral therapy for severe health anxiety

Objective: Routine outcome monitoring (ROM) is a well-evidenced means of improving psychotherapy's effectiveness. However, it is unclear how meaningful ROM is for problems that span physical and mental health, such as severe health anxiety. Physical and mental health comorbidities are common amongst severe health anxiety sufferers and cognitive behavioral therapy (CBT) is a recommended treatment. Method: Seventy-nine participants received CBT for severe health anxiety in a clinical trial. The Outcome Rating Scale (ORS: a ROM assessment of wellbeing) was completed at each session. Multilevel modeling assessed whether last-session ORS predicted health anxiety and other outcomes over 12-month follow-up. Similar models were developed using health anxiety as a comparative outcome-predictor. Outcome-improvements of treatment-responders with sudden gains were compared to those of non-sudden-gainers. Results: Last-session ORS scores predicted all outcomes up to 12 months later, with a comparable predictive effect to health anxiety. Sudden-gainers on the ORS reported significantly greater improvement in depression, functioning, and wellbeing, but no difference in health anxiety or other measures. Conclusion: The ORS may be a feasible, overall estimate of health, functioning, and quality of life in psychotherapy for severe health anxiety. Sudden gains on the ORS may be clinically meaningful with respect to some long-term outcomes.

How patients adjust psychologically to the experience of head and neck cancer: A grounded theory

Numerous physical and psychological challenges are recognised as consequences of head and neck cancer and its treatment, but little is known about how patients adjust psychologically to these experiences. This study aimed to develop a theoretical understanding of the processes patients engage in when adjusting to head and neck cancer. Twelve patients participated in semi-structured interviews conducted individually and transcribed verbatim. Data were analysed using grounded theory methodology. Analysis generated a core category of "modifying my relationship to the changes cancer brings," which encompassed 11 processes patients engaged in throughout their adjustment: "survive mode," "instrumental support from others," "making a choice," "developing own understanding," "acceptance," "talking with others," "making changes," "redefining or regaining normality," "managing emotions/distressing thoughts," "putting things into perspective" and "barriers to progress." Contrasting findings are discussed, and a model of psychological adjustment to head and neck cancer is proposed. The study found that patients engage in a series of processes throughout adjustment to head and neck cancer, which broadly map on to the cancer treatment trajectory, though these processes did not appear to be specific to head and neck cancer. The proposed model may be used as a framework to guide psychological interventions.