Doing research in non-specialist mental health services for children and young people: lessons learnt from a process evaluation of the ICALM (Interpersonal Counselling for Adolescent Low Mood) feasibility randomised controlled trial

BACKGROUND

The rising prevalence of adolescent mild depression in the UK and the paucity of evidence-based interventions in non-specialist sectors where most cases present, creates an urgent need for early psychological interventions. Randomised controlled trials (RCTs) are considered the gold standard for obtaining unbiased estimates of intervention effectiveness. However, the complexity of mental health settings poses great challenges for effectiveness evaluations. This paper reports learning from an embedded process evaluation of the ICALM RCT which tested the feasibility of delivering Interpersonal Counselling for Adolescents (IPC-A) plus Treatment as Usual (TAU) versus TAU only for adolescent (age 12-18) mild depression by non-qualified mental health professionals in non-specialist sectors.

METHODS

A qualitative mixed methods process evaluation, drawing on Bronfenbrenner's socioecological model to investigate key influences on trial delivery across macro-(e.g. policy), meso-(e.g. service characteristics) and micro-(e.g. on-site trial processes) contextual levels. Data collection methods included 9 site questionnaires, 4 observations of team meetings, policy documents, and 18 interviews with stakeholders including therapists, heads of service and managers. Thematic analysis focused on understanding how contextual features shaped trial implementation.

RESULTS

The ICALM trial concluded in 2022 having only randomised 14 out of the target 60 young people. At a macro-level, trial delivery was impacted by the COVID-19 pandemic, with services reporting a sharp increase in cases of (social) anxiety over low mood, and backlogs at central referral points which prolonged waiting times for mild cases (e.g. low mood). An interaction between high demand and lack of capacity at a meso-service level led to low prioritisation of trial activities at a micro-level. Unfamiliarity with research processes (e.g. randomisation) and variation in TAU support also accentuated the complexities of conducting an RCT in this setting.

CONCLUSIONS

Conducting a RCT of IPC-A in non-specialist services is not feasible in the current context. Failure to conduct effectiveness trials in this setting has clinical implications, potentially resulting in escalation of mild mental health problems. Research done in this setting should adopt pragmatic and innovative recruitment and engagement approaches (e.g. creating new referral pathways) and consider alternative trial designs, e.g. cluster, stepped-wedge or non-controlled studies using complex systems approaches to embrace contextual complexity.

TRIAL REGISTRATION

ISRCTN registry, ISRCTN82180413. Registered on 31 December 2019.

Interpersonal counselling for adolescent depression delivered by youth mental health workers without core professional training: a feasibility randomised controlled trial study protocol

BACKGROUND

Depression is a common health problem during adolescence and is associated with adverse academic, social and health outcomes. To meet the demand for treatment for adolescent depression, there is a need for evidence-based interventions suitable for delivery outside of specialist Child and Adolescent Mental Health Services (CAMHS). Interpersonal Counselling for Adolescents (IPC-A) is a brief manualised intervention for adolescent depression suitable for delivery by staff who are not qualified health professionals following participation in a brief training course. While initial piloting within Local Authority services has generated promising results, the effectiveness and cost-effectiveness of IPC-A has yet to be established. This study aims to assess the feasibility of a randomised controlled trial (RCT), evaluating the effectiveness and cost-effectiveness of IPC-A delivered by staff without core professional training in comparison to current provision.

METHOD

Feasibility RCT with process evaluation using ethnographic methodology. Eligible young people (n = 60) will be randomised in a 1:1 ratio to receive either IPC-A or treatment as usual (TAU). Participants will be assessed pre-randomisation (baseline) and followed up at 5, 10 and 23 weeks post-randomisation. A parallel process evaluation will generate understanding of intervention implementation across services and explore the acceptability of the intervention from the perspective of young people and other key stakeholders.

PARTICIPANTS

Young people aged 12-18 years presenting to non-specialist services with symptoms of depression. Youth workers, young people and stakeholders will participate in the process evaluation.

DISCUSSION

The need for effective and accessible interventions for young people with mild/sub-threshold depression who, in most cases, do not meet the threshold for mainstream mental health services is long overdue. The primary output of this feasibility trial will be the design of the subsequent full-scale trial. If the results of the current study indicate that this would be feasible, we intend to progress to a multi-site, assessor-blind, superiority RCT of the effectiveness and cost-effectiveness of IPC-A in comparison to TAU for adolescents presenting to non-specialist services with depressive symptoms. If satisfactory solutions to any problems encountered cannot be identified, alternative research designs will be considered. If proven effective, an IPC-A training programme could be implemented.

TRIAL REGISTRY

ISRCTN registry, ISRCTN82180413 , Registered 31 December 2019.

81 ALTERED PROTEIN COMPOSITION OF PORCINE FOLLICULAR FLUID DUE TO A HIGH-FIBRE DIET AND THE POTENTIAL FOR OPTIMISATION OF IN VITRO CULTURE MEDIA

This study reports a proteomic analyses on porcine follicular fluid (FF) obtained from a previous nutritional trial, where oocytes from gilts fed a high-fibre (HF) diet for the first 19 days of their third oestrous cycle produced blastocysts with more cells following in vitro maturation (IVM) and IVF compared with oocytes from control-fed (CON) pigs. Oocytes were matured in TCM-199 supplemented with LH and FSH at 0.5 μg mL–1 and 10% of the animals’ own pooled FF. Following IVF, resultant embryos were cultured in NCSU-23 medium for 6 to 7 days. We hypothesize that FF protein composition is altered by the HF diet and that this confers the reproductive benefits previously observed. The FF had previously been stored at –80°C after the IVF trials and was thawed for the current study, which compared the protein composition of pooled Day 19 FF from 12 CON pigs and 12 HF pigs. These gilts were a subset of the pigs described above with the largest FF volumes. The protein composition of pooled FF from 6 CON pigs whose oocytes produced blastocysts was compared with FF from 6 CON pigs whose oocytes did not produce blastocysts. The same analysis was carried out with the 6 HF pigs that produced blastocysts and the 6 HF pigs that did not produce blastocysts. Equal numbers of samples from animals were selected for experimental balance. The proteomic study was carried out in duplicate. Abundant proteins were depleted from FF by Proteominer enrichment. Samples were labelled by isotopic di-methylation, where in each analysis, one sample was labelled with a heavy methyl group, the other with a light methyl group. Proteins were detected by liquid chromatography tandem mass spectrometry. Protein identifications were filtered using a 1% false discovery threshold and a requirement for two or more peptides detected for each protein. Differentially expressed proteins (DEPs) were identified as having heavy/light ratios greater than 1.2 or less than 0.8, which are recognised cut-off points for differential expression in proteomics. Over 140 DEPs were detected between CON and HF samples, indicating a nutritional influence on FF protein composition. Over one-third (37%) of these DEPs were also differentially expressed in the blastocyst versus no blastocyst analyses, suggesting that the altered FF protein composition may affect IVF outcome. DEPs were submitted into Ingenuity Pathway Analysis to highlight associated canonical pathways and upstream regulators. Top ranking canonical pathways detected included coagulation system, acute phase response, and LXR/RXR activation pathways. Potential upstream regulators detected by IPA included transforming growth factor beta, tumour protein P53, and beta-oestradiol. These pathways and upstream regulators could serve as potential avenues for elucidating the mechanism(s) by which the HF diet results in the reproductive benefits and could lead to the refinement of IVM and IVF culture conditions. This study was funded by AHDB Pork and BBSRC.

Specific detection of the Old World screwworm fly, Chrysomya bezziana, in bulk fly trap catches using real-time PCR

The Old World screwworm fly (OWS), Chrysomya bezziana Villeneuve (Diptera: Calliphoridae), is a myiasis-causing blowfly of major concern for both animals and humans. Surveillance traps are used in several countries for early detection of incursions and to monitor control strategies. Examination of surveillance trap catches is time-consuming and is complicated by the presence of morphologically similar flies that are difficult to differentiate from Ch. bezziana, especially when the condition of specimens is poor. A molecular-based method to confirm or refute the presence of Ch. bezziana in trap catches would greatly simplify monitoring programmes. A species-specific real-time polymerase chain reaction (PCR) assay was designed to target the ribosomal DNA internal transcribed spacer 1 (rDNA ITS1) of Ch. bezziana. The assay uses both species-specific primers and an OWS-specific Taqman((R)) MGB probe. Specificity was confirmed against morphologically similar and related Chrysomya and Cochliomyia species. An optimal extraction protocol was developed to process trap catches of up to 1000 flies and the assay is sensitive enough to detect one Ch. bezziana in a sample of 1000 non-target species. Blind testing of 29 trap catches from Australia and Malaysia detected Ch. bezziana with 100% accuracy. The probability of detecting OWS in a trap catch of 50 000 flies when the OWS population prevalence is low (one in 1000 flies) is 63.6% for one extraction. For three extractions (3000 flies), the probability of detection increases to 95.5%. The real-time PCR assay, used in conjunction with morphology, will greatly increase screening capabilities in surveillance areas where OWS prevalence is low.

Infliximab in combination with methotrexate in active ankylosing spondylitis: a clinical and imaging study

OBJECTIVE

To examine the efficacy and safety of infliximab combined with methotrexate compared with methotrexate alone in the treatment of ankylosing spondylitis (AS) using MRI and DXA to monitor its impact on bone.

METHODS

In this single centre study 42 subjects with active AS were treated with methotrexate and were randomly assigned, in a ratio of 2:1, to receive five infusions of either 5 mg/kg infliximab or placebo over 30 weeks. The primary outcome was improvement in disease activity as shown by the BASDAI at week 30. MRI was used to assess the effect of treatments on sacroiliac and spinal enthesitis/osteitis and DXA to monitor bone mineral density.

RESULTS

Both therapeutic agents were well tolerated with no dropouts due to adverse events. A significantly greater improvement in mean BASDAI score was seen in the infliximab arm at week 10 (p = 0.017) than in the placebo arm, but this was not maintained by week 30 (p = 0.195), 8 weeks after the last infusion, at which stage disease flares were reported by some subjects. MRI showed that the mean number of lesions resolving for each subject from week 0 to week 30 was significantly greater in the combination group than in the methotrexate monotherapy group (p = 0.016).

CONCLUSIONS

Infliximab in combination with methotrexate was a safe and efficacious treatment in AS over 6 months and was associated with significant regression in enthesitis/osteitis as determined by MRI. However, disease flares were reported 8 weeks after the last infusion, indicating that addition of methotrexate failed to extend the infliximab dosing interval.

HIV follow-up care at a London teaching hospital

Counselling around all stages of HIV infection is important for those infected and affected with HIV disease. Partner notification may promote safer sexual practices and increase HIV-related social support which might in turn prompt the psychological adjustment to a terminal illness. This paper describes the counselling service used at the Royal Free Hospital's HIV Unit and explores the notification patterns of an HIV diagnosis to family, partners and significant others. Retrospective data was abstracted from counselling notes for 100 HIV-positive patients attending the unit for the first time between November 1995 and March 1996. The majority of the sample were gay males who tested from 1995 onwards. Most patients tested at the Same Day Testing Clinic (SDTC) were gay males. In contrast, patients who tested elsewhere were more likely to be females. Rates of pre- and post-test counselling were high and the majority (85%) of the patients had notified a family member, partner or significant other. Few significant differences in demographics were found between those who had notified others and those who had not, although patients who had been diagnosed more recently were less likely to have notified other family members. The implication of the results are discussed.

The immune response to short-term nutritional intervention in advanced chronic obstructive pulmonary disease

Nine patients with advanced chronic obstructive pulmonary disease (COPD) and recent weight loss resulting in a state of mild malnutrition were entered into a refeeding program at a clinical research center. They were divided into two groups, one using a hospital diet and the other a hospital diet with supplementation. Both groups of patients gained significant weight. Refeeding and weight gain were associated with a significant increase in absolute lymphocyte count and with an increase in reactivity to skin test antigens after 21 days of refeeding. Few changes occurred in large numbers of additional serum measurements during the study period. These preliminary observations suggest that dietary and supplementary refeeding may improve the immune responses in patients with COPD.