Using biomarkers to allocate patients in a response-adaptive clinical trial

In this paper, we discuss a response adaptive randomization method, and why it should be used in clinical trials for rare diseases compared to a randomized controlled trial with equal fixed randomization. The developed method uses a patient's biomarkers to alter the allocation probability to each treatment, in order to emphasize the benefit to the trial population. The method starts with an initial burn-in period of a small number of patients, who with equal probability, are allocated to each treatment. We then use a regression method to predict the best outcome of the next patient, using their biomarkers and the information from the previous patients. This estimated best treatment is assigned to the next patient with high probability. A completed clinical trial for the effect of catumaxomab on the survival of cancer patients is used as an example to demonstrate the use of the method and the differences to a controlled trial with equal allocation. Different regression procedures are investigated and compared to a randomized controlled trial, using efficacy and ethical measures.

Cannabidiol for Treatment-Resistant Anxiety Disorders in Young People: An Open-Label Trial

Background: Treatment resistance is a significant problem among young people experiencing moderate-to-severe anxiety, affecting nearly half of all patients. This study investigated the safety and efficacy of cannabidiol (CBD), a non-intoxicating component of Cannabis sativa, for anxiety disorders in young people who previously failed to respond to standard treatment. Methods: In this open-label trial, 31 young people aged 12-25 years with a DSM-5 anxiety disorder and no clinical improvement despite treatment with cognitive-behavioral therapy and/or antidepressant medication were enrolled between May 16, 2018, and June 28, 2019. All participants received add-on CBD for 12 weeks on a fixed-flexible schedule titrated up to 800 mg/d. The primary outcome was improvement in anxiety severity, measured with the Overall Anxiety Severity and Impairment Scale (OASIS), at week 12. Secondary outcomes included comorbid depressive symptoms, Clinical Global Impressions scale (CGI) score, and social and occupational functioning. Results: Mean (SD) OASIS scores decreased from 10.8 (3.8) at baseline to 6.3 (4.5) at week 12, corresponding to a -42.6% reduction (P < .0001). Depressive symptoms (P < .0001), CGI-Severity scale scores (P = .0008), and functioning (P = .04) improved significantly. Adverse events were reported in 25 (80.6%) of 31 participants and included fatigue, low mood, and hot flushes or cold chills. There were no serious and/or unexpected adverse events. Conclusions: These findings suggest that CBD can reduce anxiety severity and has an adequate safety profile in young people with treatment-resistant anxiety disorders. Randomized controlled trials are needed to confirm the efficacy and longer-term safety of this compound. Trial Registration: New Zealand Clinical Trials Registry (ANZCTR) identifier: ACTRN12617000825358.

Effect of 3 Forms of Early Intervention for Young People With Borderline Personality Disorder: The MOBY Randomized Clinical Trial

Importance

Clinical trials have neither focused on early intervention for psychosocial impairment nor on the contribution of components of borderline personality disorder (BPD) treatment beyond individual psychotherapy.

Objective

To evaluate the effectiveness of 3 early interventions for BPD of differing complexity.

Design, Settings, and Participants

This single-blinded randomized clinical trial recruited young people between March 17, 2011, and September 30, 2015, into parallel groups. The study took place at 2 government-funded mental health services for young people in Melbourne, Australia. Inclusion criteria were age 15 to 25 years (inclusive), recent DSM-IV-TR BPD diagnosis, and never receiving evidence-based BPD treatment. A total of 139 participants were randomized (pool of 876; 70 declined, 667 excluded), balanced for sex, age, and depressive symptomatology. Data analysis completed May 2020.

Interventions

(1) The Helping Young People Early (HYPE) dedicated BPD service model for young people, combined with weekly cognitive analytic therapy (CAT); (2) HYPE combined with a weekly befriending psychotherapy control condition; and (3) a general youth mental health service (YMHS) model, combined with befriending. Therefore, the 3 treatment arms were HYPE + CAT, HYPE + befriending, and YMHS + befriending. Participants were randomly assigned both to 1 treatment arm (in a 1:1:1 ratio) and to a clinician.

Main Outcomes and Measures

Psychosocial functioning, measured with the Inventory of Interpersonal Problems Circumplex Version and the Social Adjustment Scale Self-report.

Results

One hundred twenty-eight participants (104 [81.3%] were female; mean [SD] age, 19.1 [2.8] years; HYPE + CAT: 40 [31.3%]; HYPE + befriending: 45 [35.2%]; YMHS + befriending: 43 [33.6%]) who provided postbaseline data were included in the intent-to-treat analysis. Regardless of group, from baseline to 12 months, there was a mean of 19.3% to 23.8% improvement in the primary outcomes and 40.7% to 52.7% for all secondary outcomes, except severity of substance use and client satisfaction. The latter remained high across all time points. Planned comparisons (YMHS + befriending vs HYPE; HYPE + CAT vs befriending) showed that neither the service model nor the psychotherapy intervention was associated with a superior rate of change in psychosocial functioning by the 12-month primary end point. The HYPE service model was superior to YMHS + befriending for treatment attendance (median [IQR], 22 [19] vs 3 [16] contacts; median duration, 200 [139.5] vs 94 [125] days) and treatment completion (44 of 92 [47.8%] vs 9 of 47 [19.2%]). HYPE + CAT was superior to befriending for treatment attendance (median [IQR], 12 [16.5] vs 3 [9.8] sessions) and treatment completion (24 of 46 [52.2%] vs 29 of 93 [31.2%]).

Conclusions and Relevance

In this randomized clinical trial of 3 interventions for young people with BPD, effective early intervention was not reliant on availability of specialist psychotherapy but did require youth-oriented clinical case management and psychiatric care. A dedicated early intervention BPD service model (HYPE), with or without individual psychotherapy, achieved greater treatment attendance and completion, making it more likely to meet service user, family, and community expectations of care.

Trial Registration

anzctr.org.au Identifier: ACTRN12610000100099.

A Comparison of Adolescent versus Young Adult Outpatients with First-Presentation Borderline Personality Disorder: Findings from the MOBY Randomized Controlled Trial

OBJECTIVE

The increasing focus on adolescent personality disorder has tended to ignore evidence of the developmental continuity of the period from puberty to young adulthood. This study aims to: (1) describe the characteristics of a sample of young people with borderline personality disorder (BPD) who had no previous history of evidence-based treatment for the disorder and (2) compare their characteristics by participant age group.

METHODS

One hundred and thirty-nine young people (15 to 25 years) with BPD, newly enrolled in the Monitoring Outcomes of BPD in Youth randomized controlled trial, completed semi-structured interview and self-report measures assessing demographic, clinical, and functional characteristics. Younger (aged 15 to 17 years; n = 64) and older (aged 18 to 25 years; n = 75) participants were compared on these same variables using t-tests, chi-square tests, and logistic regression.

RESULTS

Young outpatients with BPD had extensive and severe psychopathology and were functioning poorly. Adolescents and young adults with BPD showed substantial similarities on 20 key aspects of their presentation. Significant between-groups differences were observed in household makeup, treatment history, antisocial personality disorder, emotion dysregulation, substance use, age of commencement and extent of self-harm, and achievement of age-appropriate educational milestones. Adolescent BPD group membership was predicted by family composition and self-harm, whereas young adult BPD group membership was predicted by not achieving age-appropriate milestones, vocational disengagement, and emotion dysregulation. The final model explained 54% of the variance and correctly classified 80.2% of the sample by age.

CONCLUSIONS

Both adolescents and young adults with early stage BPD present with severe and often similar problems to one another, supporting developmental continuity across this age range. However, there are also meaningful differences in presentation, suggesting that pathways to care might differ by age and/or developmental stage. Detection and intervention for personality disorder should not be delayed until individuals reach 18 years of age.

Enhancing the contribution of clinical psychology: an under-utilised workforce in public mental health services

OBJECTIVE

Clinical psychologists are practitioners with expertise in mental health, who apply advanced psychological theory and knowledge to their practice in order to assess and treat complex psychological disorders. Given their robust specialised mental health training, clinical psychology is an integral component of the Australian mental health workforce, but is under-utilised. Recent reviews have identified significant problems with Australia's mental health system, including unequal access to clinical psychology services and fragmentation of service delivery, including convoluted pathways to care.

CONCLUSIONS

Clinical psychology is well placed to contribute meaningfully to public mental health services (PMHS). We describe what clinical psychologists currently contribute to team-based care in PMHS, how we could further contribute and the barriers to making more extensive contributions. We identify significant historical and organisational factors that have limited the contribution made by clinical psychologists and provide suggestions for cultural change to PMHS.

433 SAME SPECIALITY, DIFFERENT REALITY?

Introduction

The United Kingdom and Spain run government-funded social and health care services, free for the user at the point of delivery. Acute Geriatric Units (AGU) carrying out Comprehensive Geriatric Assessments improve the clinical outcomes of older patients. Little is known about the similarities and differences between countries, and how these may impact on clinical outcomes.

Methods

Prospective observational study of consecutive patients admitted to AGU of 2 hospitals in the UK and 4 hospitals in Spain between the 1st to the 30th of October 2019 and from the 1st to the 29th of February 2020. We followed up the patients for a 90 day period.

Conclusions

Frailty, multimorbidity and polypharmacy were prevalent in both cohorts. English patients were younger, with shorter hospital stay, mortality and use of antipsychotic medication but higher readmission rates. Involvement from Allied health care professionals was higher in UK hospitals.

Number of Borderline Personality Disorder Criteria and Depression Predict Poor Functioning and Quality of Life in Outpatient Youth

This study aimed to investigate which factors contribute to poor functioning and poor quality of life in youth (aged 15-25 years) with borderline personality disorder (BPD), and whether the number of BPD criteria might be an independent predictor of these outcomes. A sample of 499 help-seeking outpatient youth, aged 15-25 years, was assessed. Stepwise multiple regression analyses showed that the number of BPD criteria was the best predictor of poor functioning, followed by number of mental health visits in the past month, female sex, and a current diagnosis of depression. Current depression was the best predictor of Assessment of Quality of Life utility score, followed by the number of BPD criteria. These findings underscore the clinical significance of DSM-IV BPD features (even when subthreshold for a categorical diagnosis) in youth and their effects upon social and occupational functioning and quality of life early in the course of BPD.

Testing the Interpersonal-Cognitive Model of Auditory Verbal Hallucinations in Youths with Either Early-Stage Borderline Personality Disorder or First-Episode Schizophrenia Spectrum Disorder

This is the first study to explore interpersonal schemata in outpatient youths (age 15-25 years) with early-stage borderline personality disorder (BPD) and auditory verbal hallucinations (AVH). It also aimed to replicate, in a transdiagnostic youth sample, the finding from studies of adults with AVH that negative beliefs about the self and others lead to negative appraisals of voices, which in turn elicits depression. The following 3 groups were compared: youth with BPD+AVH (n = 23), youth with schizophrenia spectrum disorder (SZ) with AVH (SZ+AVH, n = 20), and youths with BPD who did not experience AVH (BPD no AVH, n = 23). The BPD+AVH group reported more negative and fewer positive self schemata than the SZ+AVH group. They also saw themselves as being more socially inferior to others than did the SZ+AVH group, but they did not differ in appraisals of self or others, compared with the BPD no AVH group. In youths with AVH (BPD+AVH, SZ+AVH combined), the indirect effect of beliefs about self or others, via negative appraisals of voices on depression, was not significant. Instead, a significant indirect effect of negative appraisals of voices on depression, via negative beliefs about self, was found. The experience of AVH during adolescence and young adulthood, when the identity is still being formed, might have a more profound effect on the developing self than during later adulthood, when the self is more stable and resilient. Negative self-appraisals might constitute a treatment target for early intervention for youths with distressing voices, including those with BPD.

Aripiprazole compared with placebo for auditory verbal hallucinations in youth with borderline personality disorder: Protocol for the VERBATIM randomized controlled trial

AIM

Up to half of patients with borderline personality disorder report auditory verbal hallucinations that are phenomenologically indistinguishable from those in schizophrenia, occur early in the course of the disorder, and are enduring, distressing and disabling. In clinical practice, this symptom is widely assumed to be unresponsive to treatment with antipsychotic medication and early intervention is rarely offered. The Verbal Experiences Response in Borderline personality disorder to Aripiprazole TrIal Medication (VERBATIM) study aims to be the first controlled trial to investigate the effectiveness of conventional pharmacotherapy for this symptom in this patient group.

METHOD

VERBATIM is a 12-week, triple-blind, single-centre, parallel groups randomised controlled trial, with a 27-week follow-up period. Participants between the ages of 15 and 25 years receive either aripiprazole or placebo daily, commencing at 2 mg and increasing to 10 mg by day 15. Further dose escalations (up to 30 mg) may occur, as clinically indicated. This trial was prospectively registered with the Australian and New Zealand Clinical Trials Registry ACTRN12616001192471 on 30/08/2016.

RESULTS

The primary outcome is severity of auditory verbal hallucinations assessed using the Psychotic Symptom Rating Scale. Secondary outcomes include the severity of general psychopathology, borderline personality pathology, social and occupational functioning and change in brain resting state connectivity. The primary endpoint is week 12 and secondary endpoint is week 39.

CONCLUSION

The results will inform treatment decisions for individuals with borderline personality disorder who present with auditory verbal hallucinations.

Improving functional outcomes in early-stage bipolar disorder: The protocol for the REsearch into COgnitive and behavioural VERsatility trial

AIM

Young people with bipolar disorder (BD) commonly experience reduced quality of life, persistent symptoms and impaired functional recovery despite often superior school performance. Compromised long-term functioning can ensue. There is evidence that psychological therapies alongside pharmacology may be more efficacious earlier in the course of the disorder. Intervention in the early stages may thus reduce the burden and risk associated with BD and mitigate the impact of the disorder on normal developmental trajectories. To date, however, the availability of evidence-based psychological therapies for young people with early BD is limited. Furthermore, there are no large-scale randomized controlled trials (RCTs) of such interventions.

METHODS

The study is a prospective, single-blind, RCT examining the effectiveness of an adjunctive individualized and manualized psychological intervention, compared with treatment as usual within youth-specific early intervention services. The REsearch into COgnitive and behavioural VERsatility (RECOVER) intervention is delivered over a 6-month period. About 122 young people in the early stages of BD-I (at least one manic episode in the previous 2 years, with no more than five lifetime treated/untreated manic or hypomanic episodes) will be recruited. The assessments will occur at baseline, 3, 6 (primary endpoint, end of treatment), 9, 12, 15 and 18 months.

RESULTS

Recruitment will commence in January 2019 and is anticipated to occur over a 3.5-year period.

CONCLUSIONS

To date, there are no evidence-based psychological therapies tailored to young people with early BD. We will test whether early psychological intervention in the course of BD can reduce the symptomatic, psychological, vocational and social impacts that are seen in entrenched disorder.

Determination of Total Fumonisins in Corn by Competitive Direct Enzyme-Linked Immunosorbent Assay: Collaborative Study

Fumonisins—mycotoxins produced by some Fusarium species—have been shown to be the causative agent of diseases in horses and other domesticated animals as well as possible carcinogens in humans. A collaborative study was conducted to evaluate the effectiveness of a competitive direct enzyme-linked immunosorbent assay (CD-ELISA) for the determination of total fumonisins (B1, B2, and B3) in corn. The test portion was extracted with methanol–water (7 + 3), filtered, diluted, and tested on the CD-ELISA. Naturally and artificially contaminated corn test portions were sent to 13 collaborators in the United States. Naturally contaminated field test portions were prepared at 3 different levels. Artificially contaminated test portions were spiked at 1.0, 3.0, and 5.0 mg/kg total fumonisins (B1, B2, and B3). Average recoveries of total fumonisins were 120, 100, and 90%, respectively. The relative standard deviations for repeatability ranged from 13.3 to 23.3% and the relative standard deviations for reproducibility ranged from 15.8 to 30.3% across all levels tested. HORRAT values, calculated for each individual sample, ranged from 1.24 to 1.94. This method demonstrated acceptable intra- and interlaboratory precision at the levels tested.

Exploratory comparison of auditory verbal hallucinations and other psychotic symptoms among youth with borderline personality disorder or schizophrenia spectrum disorder

OBJECTIVE

This study explored phenomenological aspects of auditory verbal hallucinations (AVH) and other psychotic symptoms among youth with borderline personality disorder (BPD).

METHODS

Sixty-eight outpatients, aged 15 to 25 years, were categorized into three groups according to their primary Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis and AVH symptom profile; BPD + AVH (n = 23), schizophrenia spectrum disorder (SZ) + AVH (n = 22) and BPD with no AVH (n = 23).

RESULTS

No differences in AVH were found between BPD + AVH and SZ + AVH. Compared with SZ + AVH, BPD + AVH scored lower on delusions and difficulty in abstract thinking and higher on hostility. BPD + AVH reported more severe self-harm, paranoid ideation, dissociation, anxiety and stress than BPD no AVH.

CONCLUSIONS

This study replicates, in a sample of youth, the finding from studies of adults that AVH in BPD are indistinguishable from those in SZ, when assessed with the Psychotic Symptom Rating Scales (PSYRATS). Clinicians should specifically enquire about AVH among youth with BPD. When present, AVH appear to be an indicator of a more severe form of BPD.

Understanding what it means to be socially included for people with a lived experience of mental illness

AIMS

Social inclusion is increasingly understood to have positive and beneficial implications for the mental health outcomes of people with severe mental illness. The concept is plagued by definitional inconsistencies and a lack of consensus regarding what it means to be socially included, in particular for groups most vulnerable to social exclusion, such as people with mental illness. The aim of this study was to obtain a consensus regarding the key contributors to social inclusion from the perspective of people with and without a lived experience of mental illness (consumers of mental health services, carers, and general community members).

METHODS

Delphi methodology was employed to reach consensus agreement. The Delphi questionnaire was based on a previous review of the literature and consisted of 147 items categorized into 13 domains. It was presented to participants over three rounds. Participants (N = 104) were recruited into three groups (32 consumers, 32 carers of people with a mental illness, and 40 members of the general community - neither consumers nor carers). Retention of participants from Round 1 to Round 3 was 79.8%.

RESULTS

Similarities and differences were observed between the groups. A number of items were very strongly endorsed as key contributors to social inclusion, relating to social participation, social supports, housing, neighbourhood, community involvement, employment and education, health and well-being and service utilization.

CONCLUSION

Findings supported previous work, indicating the importance of having a strong sense of connection with others as well as the importance of safe and stable housing, support services and personal motivation and hope. We obtained a well-rounded perspective among groups regarding the key contributors to social inclusion, with a particular relevance to people living with mental illness. This perspective has significant clinical and research utility.

The Clinical Significance of Subthreshold Borderline Personality Disorder Features in Outpatient Youth

Studies among adult patients have found that subthreshold borderline personality disorder (BPD) features are associated with elevated psychosocial morbidity compared with patients with no BPD features. However, the clinical significance of subthreshold features of BPD has not been investigated among real-world patients during the clinical emergence of the disorder, which is usually between puberty and emerging adulthood. This study aimed to replicate and extend previous research by comparing outpatient youth aged 15-25 years with subthreshold BPD features with youth with no BPD features. The sample included 499 potential participants, of whom 111 had no DSM-IV BPD features at all, and 155 had between one and four features. Results indicated that the group with subthreshold BPD features had more severe mental illness and poorer social and occupational functioning. These findings suggest that subthreshold BPD features are clinically important and should be a focus of clinical intervention to reduce continuing disability and improve outcome.

Preliminary Evidence for the Cognitive Model of Auditory Verbal Hallucinations in Youth With Borderline Personality Disorder

Objectives: This is the first study to explore cognitive, emotional, and behavioral responses to voices in youth with borderline personality disorder (BPD) compared with those with schizophrenia spectrum disorder (SZ), and to examine if negative appraisals of voices predict depression and anxiety across the groups. Methods: The sample comprised 43 outpatients, aged 15-25 years, who reported auditory verbal hallucinations (AVH) and were diagnosed with either Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) BPD or SZ. Data were collected using the Psychotic Symptom Rating Scales, the revised Beliefs About Voices Questionnaire, the Voice Rank Scale, and the Depression Anxiety Stress Scale. Results: Youth with BPD did not differ from youth with SZ in beliefs about the benevolence or malevolence of voices. Youth with BPD appraised their voices as more omnipotent and of higher social rank in relation to themselves, compared with youth with SZ. In both diagnostic groups, beliefs about malevolence and omnipotence of voices were correlated with more resistance toward voices, and beliefs about benevolence with more engagement with voices. In addition, perceiving the voices as being of higher social rank than oneself and negative voice content were both independent predictors of depression, irrespective of diagnostic group. In contrast, negative appraisals of voices did not predict anxiety after adjusting for negative voice content. Conclusions: This study replicated the link between negative appraisals of voices and depression that has been found in adults with SZ in a mixed diagnostic youth sample. It, thus, provides preliminary evidence that the cognitive model of AVH can be applied to understanding and treating voices in youth with BPD.

Comparing immediate-type food allergy in humans and companion animals-revealing unmet needs

Adverse food reactions occur in human as well as veterinary patients. Systematic comparison may lead to improved recommendations for prevention and treatment in both. In this position paper, we summarize the current knowledge on immediate-type food allergy vs other food adverse reactions in companion animals, and compare this to the human situation. While the prevalence of food allergy in humans has been well studied for some allergens, this remains to be investigated for animal patients, where owner-reported as well as veterinarian-diagnosed food adverse reactions are on the increase. The characteristics of the disease in humans vs dogs, cats, and horses are most often caused by similar, but sometimes species-dependent different pathophysiological mechanisms, prompting the specific clinical symptoms, diagnoses, and treatments. Furthermore, little is known about the allergen molecules causative for type I food allergy in animals, which, like in human patients, could represent predictive biomarkers for risk evaluation. The definite diagnosis of food allergy relies-as in humans-on elimination diet and provocation tests. Besides allergen avoidance in daily practice, novel treatment options and tolerization strategies are underway. Taken together, numerous knowledge gaps were identified in veterinary food allergy, which need to be filled by systematic comparative studies.

Depression as a risk factor for fracture in women: A 10 year longitudinal study

BACKGROUND

Previous research has demonstrated deficits in bone mineral density (BMD) among individuals with depression. While reduced BMD is a known risk for fracture, a direct link between depression and fracture risk is yet to be confirmed.

METHODS

A population-based sample of women participating in the Geelong Osteoporosis Study was studied using both nested case-control and retrospective cohort study designs. A lifetime history of depression was identified using a semi-structured clinical interview (SCID-I/NP). Incident fractures were identified from radiological reports and BMD was measured at the femoral neck using dual energy absorptiometry. Anthropometry was measured and information on medication use and lifestyle factors was obtained via questionnaire.

RESULTS

Among 179 cases with incident fracture and 914 controls, depression was associated with increased odds of fracture (adjusted odds ratio (OR) 1.57, 95%CI 1.04-2.38); further adjustment for psychotropic medication use appeared to attenuate this association (adjusted OR 1.52, 95%CI 0.98-2.36). Among 165 women with a history of depression at baseline and 693 who had no history of depression, depression was associated with a 68% increased risk of incident fracture (adjusted hazard ratio (HR) 1.68, 95%CI 1.02-2.76), with further adjustment for psychotropic medication use also appearing to attenuate this association (adjusted HR 1.58, 95%CI 0.95-2.61).

LIMITATIONS

Potential limitations include recall bias, unrecognised confounding and generalizability.

CONCLUSIONS

This study provides both cross-sectional and longitudinal evidence to suggest that clinical depression is a risk factor for radiologically-confirmed incident fracture, independent of a number of known risk factors. If there is indeed a clinically meaningful co-morbidity between mental and bone health, potentially worsened by psychotropic medications, the issue of screening at-risk populations needs to become a priority.

Comparing three forms of early intervention for youth with borderline personality disorder (the MOBY study): study protocol for a randomised controlled trial

Background

Borderline personality disorder is a severe mental disorder that usually has its onset in youth, but its diagnosis and treatment are often delayed. Psychosocial ‘early intervention’ is effective in improving symptoms and behaviours, but no trial has studied adaptive functioning as a primary outcome, even though this remains the major persistent impairment in this patient group. Also, the degree of complexity of treatment and requirements for implementation in mainstream health services are unclear.

The primary aim of this trial is to evaluate the effectiveness of three forms of early intervention for borderline personality disorder in terms of adaptive functioning. Each treatment is defined by combining either a specialised or a general service delivery model with either an individual psychotherapy or a control psychotherapy condition.

Methods/design

The study is a parallel-group, single-blind, randomised controlled trial, which has randomised permuted blocking, stratified by depression score, sex and age. The treatments are: (1) the specialised Helping Young People Early service model plus up to 16 sessions of individual cognitive analytic therapy; (2) the Helping Young People Early service plus up to 16 sessions of a control psychotherapy condition known as ‘befriending’; (3) a general youth mental health care model plus up to 16 sessions of befriending. Participants will comprise 135 help-seeking youth aged 15–25 years with borderline personality disorder. After baseline assessment, staff blind to the study design and treatment group allocation will conduct assessments at 3, 6, 12 and 18 months. At the 12-month primary endpoint, the primary outcome is adaptive functioning (measures of social adjustment and interpersonal problems); secondary outcomes include measures of client satisfaction, borderline personality disorder features, depression and substance use.

Discussion

The results of this trial will help to clarify the comparative effectiveness of a specialised early intervention service model over and above general youth mental health care, along with the contribution of individual cognitive analytic therapy over and above specialised general clinical care in early intervention for borderline personality disorder. Consequently, the findings will also inform the level of training and competency required for effective delivery of early intervention services.

Trial registration

Registered with the Australian New Zealand Clinical Trial Registry ACTRN12610000100099 on 1 February 2010.

Moderators and Predictors of Response to Eating Disorder Risk Factor Reduction Programs in Collegiate Female Athletes

OBJECTIVE

The primary aim of this paper was to investigate moderators and predictors of response to two programs designed to reduce eating disorder risk factors in collegiate female athletes. This study served as an ancillary study to a parent trial that investigated the feasibility of an athlete modified cognitive dissonance-based program (AM-DBP) and an athlete modified healthy weight intervention program (AM-HWI).

DESIGN

157 female collegiate athletes were randomized to either the AM-DBP or the AM-HWI program. Participants completed surveys at baseline, post-intervention, 6 weeks, and 1 year.

METHODS

After classifying sports as either lean or non-lean, we investigated if sport type acted as a moderator of program response to AM-DBP and AM-HWI using ANOVAs. Next, we examined whether baseline thin-ideal internalization, weight concern, shape concern, bulimic pathology, dietary restraint, and negative affect acted as predictors of changes in bulimic pathology using linear regression models.

RESULTS

Athletes in non-lean sports who received AM-DBP showed more improvement in negative affect versus non-lean sport athletes in AM-HWI. Higher baseline scores of bulimic pathology predicted greater response in bulimic pathology to both programs at 6-weeks. In contrast, athletes with higher dietary restraint and negative affect baseline scores showed decreased response to both interventions at 6-weeks. Finally, athletes with higher baseline shape concern showed a decreased response to the AM-HWI intervention at the post intervention time point.

CONCLUSION

Results from the present study indicate that lean/non-lean sport may not play a strong role in determining response to efficacious programs. Further, factors such as pre-existing bulimic pathology, dietary restraint, negative affect, and shape concern may affect general response to intervention versus specific responses to specific interventions.

A prospective study of the impact of floods on the mental and physical health of older adults

OBJECTIVES

With a longitudinal prospective design, we examined the impact of floods on the mental and physical health of older adults and explored risk and protective factors.

METHOD

Two hundred and seventy four older adults (age ≥60) completed surveys before and after a flood event. Both the surveys included measures of anxiety, depression, self-reported health, and satisfaction with life; the post-flood survey also included questionnaires on flood experience, symptoms of post-traumatic stress disorder (PTSD), stoicism, and psychological coping with floods.

RESULTS

Compared to those not personally affected (78.8%), personally affected individuals (21.2%) reported significantly higher PTSD symptoms, with about one in six reporting PTSD symptoms that might require clinical attention. Personally affected individuals also reported a greater increase in anxiety post-flood, but changes in their depressive symptoms and self-reported health were not significantly different from those not personally affected. Greater flood exposure and the lack of social support were the risk factors for poorer mental and physical health. Higher stoicism was associated with higher post-flood depression and poorer self-reported mental health. The use of maladaptive coping, such as venting and distraction, was associated with greater deterioration in mental health after floods, whilst emotion-focused coping such as acceptance, positive reframing, and humour, was protective against such deterioration.

CONCLUSION

Floods had adverse psychological impacts on some older adults who were personally affected. Despite the evidence of resilience, a small proportion of older adults experienced significant difficulties after the floods. The findings in this study help understand older adults' psychological responses to disasters and have practical implications for service planning and delivery.

Separated response function ratios in exclusive, forward π(±) electroproduction

The study of exclusive π(±) electroproduction on the nucleon, including separation of the various structure functions, is of interest for a number of reasons. The ratio RL=σL(π-)/σL(π+) is sensitive to isoscalar contamination to the dominant isovector pion exchange amplitude, which is the basis for the determination of the charged pion form factor from electroproduction data. A change in the value of RT=σT(π-)/σT(π+) from unity at small -t, to 1/4 at large -t, would suggest a transition from coupling to a (virtual) pion to coupling to individual quarks. Furthermore, the mentioned ratios may show an earlier approach to perturbative QCD than the individual cross sections. We have performed the first complete separation of the four unpolarized electromagnetic structure functions above the dominant resonances in forward, exclusive π(±) electroproduction on the deuteron at central Q(2) values of 0.6, 1.0, 1.6  GeV(2) at W=1.95  GeV, and Q(2)=2.45  GeV(2) at W=2.22  GeV. Here, we present the L and T cross sections, with emphasis on RL and RT, and compare them with theoretical calculations. Results for the separated ratio RL indicate dominance of the pion-pole diagram at low -t, while results for RT are consistent with a transition between pion knockout and quark knockout mechanisms.

Antecedents of Attitudes to Aging: A Study of the Roles of Personality and Well-being

PURPOSE OF THE STUDY

Little research has examined factors that contribute to the formation of attitudes toward one's own aging. The current study aimed to examine personality as defined by the Five-Factor model of personality as an antecedent of attitudes, while taking into account demographic and health factors known to be relevant to such attitudes.

DESIGN AND METHODS

Participants aged 60 years or older (N = 421) were part of a longitudinal study of health and well-being in Australia, and completed a postal survey comprising measures of personality, the Attitudes to Ageing Questionnaire, the SF-12 health survey, and the Satisfaction with Life Scale.

RESULTS

Higher levels of neuroticism were associated with less positive attitudes toward old age as a time of psychological growth, and higher extraversion and agreeableness were significant predictors of less negative attitudes toward psychosocial loss. Baseline measures of self-reported mental and physical health, as well as change in those scores, also made significant contributions to attitudes toward aging.

IMPLICATIONS

Personality was a significant antecedent of attitudes towards aging, as were mental and physical health. The data highlight the role of potentially modifiable factors, such as mental and physical health. If these factors act as resources that shape an individual's attitudes during the aging process, then one potential foundation for holding positive attitudes to aging is to maintain physical and mental health. This requires interventions and policies that are effective in encouraging health-promoting behaviors.

A randomized controlled trial of vocational intervention for young people with first-episode psychosis: method

AIM

Young people who are experiencing first-episode psychosis (FEP) are at increased risk of being unemployed compared to either their same age peers in the general population, or those with other mental illnesses. Significant research has been conducted examining employment interventions for those with chronic psychotic illness. This has yielded strong results in favour of an intervention called individual placement and support (IPS). However, significantly less work has examined the benefit of this approach to those in FEP when the potential for vocational rehabilitation is perhaps greater. This study adds to the knowledge of vocational intervention in first-episode psychotic illness. Additionally, it expands this work into the areas of cognition, social cognition, social inclusion and economics.

METHODS

The study is a single-blind, randomized controlled trial comparing receiving high-quality FEP treatment as usual plus IPS (IPS + TAU) to a FEP treatment as usual (TAU) intervention alone within a specialized FEP service.

RESULTS

The study recruited 146 people attending a first-episode psychosis service over 2 years. They were assessed at baseline, 6 months (end of intervention) 12 and 18 months with a battery covering psychopathology, economic, demographic, social cognitive, cognitive and diagnostic variables.

CONCLUSIONS

This paper describes the methodology for the largest attempted study of IPS in FEP. This study has the capacity to answer questions about the benefits on illness and economic impacts of vocational recovery in FEP. Further, it has the capacity to extend knowledge about the contribution of cognitive and social cognitive factors to recovery in this domain.

British Dietetic Association evidence-based guidelines for the protein requirements of adults undergoing maintenance haemodialysis or peritoneal dialysis

BACKGROUND

Existing nutritional guidelines suggest that protein requirements of adults with stage five chronic kidney disease undergoing haemodialysis (HD) or peritoneal dialysis (PD) are increased as a result of protein losses during dialysis. The present review aimed to update previous guidance and develop evidence-based practice guidelines on the protein requirements of adults undergoing maintenance dialysis.

METHODS

Following a PICO approach (Participants or Population, Intervention or Exposure, Comparison and Outcome), four research questions were formulated to investigate the total protein requirement and protein quality required by adults undergoing HD and PD. A comprehensive, systematic review was undertaken using the databases Medline, EMBASE and the Cochrane Library from 2005 to September 2009 for HD studies and from 1997 to September 2009 for PD studies.

RESULTS

The literature search yielded 2931 studies, which were assessed for inclusion. Following appraisal, 19 studies in HD and 18 studies in PD met the inclusion criteria and were systematically reviewed. Limited good quality evidence supports the recommendations that: (i) adults undergoing maintenance HD require a minimum protein intake of 1.1 g kg(-1) ideal body weight (IBW) per day; and (ii) adults undergoing maintenance PD require a minimum protein intake of 1.0-1.2 kg(-1) IBW per day, in conjunction with an adequate energy intake. There were no studies that addressed the quality of protein for either HD or PD.

CONCLUSIONS

Evidence suggests that nutritional status may be maintained with lower protein intakes than previously recommended. However, the evidence base is limited and further randomised controlled trials are required to establish the optimal protein intake for dialysis patients.

Validation of the Drinking Motives Questionnaire (DMQ) in older adults

Drinking motives have been established as an important construct in the prediction of alcohol use and drinking problems among younger adults, but there is little understanding about the drinking motivations of older adults. Although emerging evidence shows the importance of studying older adults' own reasoning for their alcohol consumption, measures that have been used to assess such reasons lack psychometric assessment. This study aims to validate the three-dimensional structure of the Drinking Motives Questionnaire (DMQ) in older adults and to investigate the relationships between drinking motives and alcohol use. A sample of community dwelling older adults (N=370) completed self-report measures assessing drinking behavior and motives for drinking. Using confirmatory factor analysis, the results supported a three-factor model of drinking motives. Multi-group analysis of invariance showed support for configural and metric invariance, and partial support was met for scalar invariance. Social motivations for drinking were the most frequently endorsed, followed by enhancement, and coping motives. Males reported more frequent drinking for each of the three motives. Social motives were consistently related to drinking behaviors and coping had a direct relationship to drinking problems. Overall, the study shows that the DMQ has promise as a measure for use with older adults.

Attentional processes and responding to affective faces in youth with borderline personality features

This study examined attentional biases for emotional faces in borderline personality disorder (BPD). Twenty-one outpatient youth (aged 15-24 years) meeting three or more DSM-IV BPD criteria and 20 community-derived participants (aged 15-24 years) with no history of psychiatric problems and not meeting any BPD criteria completed a modified dot-probe task that tested automatic (30 ms) and controlled (500 ms) stages of information processing. The findings indicate that, compared with healthy controls, youth with borderline features were faster to respond to congruent rather than incongruent fear stimuli. This effect was independent of state anxiety and was observed during the 30 ms presentation of fearful faces. There was no significant effect for happy or angry faces. Youth with borderline features were also slower to respond to incongruent rather than paired neutral trials, indicating difficulties in disengaging attention from the perceived threat. Such differences were not found for the healthy controls. Thus, youth with borderline features had an attentional bias for fearful faces that reflected difficulty in disengaging attention from threatening information during pre-conscious stages of attention. This finding extends previous research highlighting the diminished capacity for affect regulation and subsequent engagement in behavioural strategies to avoid distress in BPD. Future research should explore the relationship between information processing, emotion regulation in adult BPD samples.

The profile of suicide: changing or changeable?

PURPOSE

The aims of this study were to: (1) examine the role of psychosocial factors, physical and mental health in suicide; (2) to examine gender differences on those variables; and (3) determine whether there was a group who died by suicide who did not have a history of mental illness.

METHOD

Data were obtained from The Australian National Coroners Information System (NCIS) for all deaths classified as suicides from 2000 to 2004 in all Australian states. The NCIS is an internet-based system for storing and retrieving data on coronial cases.

RESULTS

The overall results from the total sample reinforces many previous findings but also found some differences; importantly, psychiatric morbidity was less than generally reported, and comparable proportions of males and females used violent means to suicide. Using latent class analysis the study identified four clusters of people who had suicided. In two of those clusters mental illness appeared to be a significant factor; in one of those two clusters the mental illness was compounded by additional drug and alcohol and relationship problems whilst the other was without such levels of comorbidity. The third group was predominantly male, older and physical illness seemed to be a significant factor. The final group was characterised by low rates of mental illness and treatment for the same, but marked by relationship and financial difficulties.

CONCLUSIONS

These data may suggest that the profile of suicide is changing or changeable. Certainly there has been a shift in the gender profile with comparable proportions of women and men. Whilst mental illness remains a major risk factor, perhaps greater emphasis needs to be placed on the broader psychosocial issues which may initiate or hasten the pathway to suicide. In addition, it may be that the relative contribution of mental illness and other factors is fluid in relation to both life stage and life circumstances. Suicide prevention programmes might usefully define a range of discrete areas of work.

Emotional sensitivity in youth with borderline personality pathology

If Borderline Personality Disorder (BPD) is characterized by an underlying emotional sensitivity, individuals with this disorder would be expected to demonstrate accurate identification of emotional expressions at earlier stages of expression (i.e., lower thresholds of facial expressivity across all emotional valences). Twenty-one outpatient youth (aged 15-24 years) meeting 3 or more DSM-IV BPD criteria and 20 community-derived participants (aged 15-24 years) with no history of psychiatric problems were tested on a measure of emotional sensitivity, the Face Morph Task. In this test faces morph from neutral to each of the six basic emotional expressions. The BPD group showed no evidence of heightened sensitivity to emotional facial expressions compared to the community control group (all P>0.05 and effect sizes ranging from 0 to 0.6). They require comparable levels of emotional expressivity in order to correctly identify emotions. Therefore, emotional sensitivity might not be apparent early in the course of BPD. Rather, it might develop later in the course of the disorder or be present only in severe BPD.

The detection of malingering in memory performance: The sensitivity and specificity of four measures in a UK population

OBJECTIVES

To investigate the validity of a clinical neuropsychological battery for the detection of malingering on tests of memory.

METHODS

A simulated scenario design was developed to investigate the effectiveness of a battery of four neuropsychological tests in the detection of malingering; the Coin in the Hand Test (CIH), Autobiographical Memory Index (AMI), Rey I 5-Item Test (RIT),and the Wechsler Mental Control Test (MCT). The performances of patients with an acquired brain injury (N = 40) were compared with two groups of controls instructed either to simulate a head injury performance (N = 40) or do their best (N = 40).

RESULTS

The CIH and MCT demonstrated good validity and displayed high sensitivity and specificity. The RIT and the AMI was relatively poor in distinguishing between simulators and patients.

CONCLUSIONS

The sensitivity and specificity of all four tests to the detection of malingering has been assessed. Two of the tests the CIH and MCT would be useful as a quick and accurate screening tool for detecting malingering.

STUDIES OF DISEASES OF THE LYMPHOID AND MYELOID TISSUES. I : THE CHEMICAL METABOLISM OF NORMAL AND PATHOLOGICAL LYMPH NODES

From a study of the metabolism of 71 lymph nodes and tumors one may conclude: 1. The nature of a tumor can not be predicted from the metabolism because too much overlapping of metabolic rates exists between the pathological groups. 2. There is no evidence metabolically one way or another as to whether malignant lymphomata of any type should be classed as neoplastic or as infectious processes. 3. The degree of cell differentiation can in most cases be foretold by the percentage difference between the aerobic and the anaerobic glycolysis. The greater the differentiation the greater the percentage difference. Sarcomata in general constitute an exception to this rule. 4. The degree of malignancy in carcinoma, but not in other tumors, can, with certain exceptions, be predicted from the height of the value U. 5. Human sarcomata appear to have a metabolism far more closely comparable to that of benign tumors than to that of carcinomata. They do not behave as malignant tumors under the Warburg classification. Their energy requirements are not of the same order as those of carcinoma. 6. One can not from the value U or from the glycolytic rates predict whether or not a tissue should be classed as neoplastic. 7. Warburg's findings for carcinomata are confirmed and amplified.