Arts for the Blues - a new creative psychological therapy for depression: a pilot workshop report

INTRODUCTION

Research over the last decade has identified both strengths and limitations in the use of routinely prescribed psychological therapies for depression. More recently, a focus on how creative art therapies and 'arts on prescription' are developing a growing recognition of their potential additional therapeutic mechanisms for depression.

AIM

In an attempt to develop a new therapeutic intervention for depression, this research aligned both the evidence base surrounding the arts on prescription movement, collating these with client-reported helpful factors and preferences for therapeutic interventions.

METHODS

We developed a framework for a new pluralistic 'meta-approach' of therapy for depression, based on; an interdisciplinary thematic synthesis of active ingredients, considered specific features implemented in therapy, and client-reported helpful factors considered to be the broad features or experiences in therapy from both talking therapies and creative approaches. This framework contributed to the development of a pilot workshop entitled Arts for the Blues - A New Creative Psychological Therapy for Depression. An outline of, and evaluation from this workshop is presented in this article. Workshop participants were recruited via a voluntary workshop taking place at a North West Higher Education Institution Arts and Health conference ( N = 15).

RESULTS

The workshop was evaluated using quantitative measures, with results indicating around a 70% overall satisfaction, followed up with qualitative commentary around areas of good practice and areas for development. These included the positive reflection on the application of creative arts and the multimodal nature of the approach, while others reflected on the potential overwhelming nature of utilising multimodal methods for individuals with depression.

CONCLUSION

Overall feedback from the pilot workshop is discussed in relation to prior research, giving credence to the potential for incorporating arts into therapy.

Linking implementation to outcomes: evaluation of a community-based breast and cervical cancer screening program

An implementation analysis of the first eighteen months of the Maryland Breast and Cervical Cancer Program examined the variability among participating local agencies in the extent of screening services delivered; local program implementation processes; and the relationships between extent of screening and the local level processes. The study used: 1) a mail and telephone survey of local health departments (LHD, N = 24) and 2) state program surveillance data, with correlational methods.

OUTCOMES MEASURED

1) "Penetration," the proportion of the target population screened; and 2) "Efficiency," the number of women screened per program staff member. Categories of implementation variables were: 1) Environment, 2) Staffing, 3) Collaboration with community organizations, 4) Outreach, 5) Provider variables, 6) Relationships with State and LHDs, 7) Organizational variables, and 8) Service delivery. Results showed wide local variability in screening levels. Availability of local resources; provider involvement; success of community linkages; and local health department readiness showed relationships with the extent of local screening. Studying implementation is needed to improve the effectiveness and efficiency of community-based programs.

Gestational diabetes screening and glycaemic management; national survey on behalf of the Association of British Clinical Diabetologists

BACKGROUND

There is no UK consensus for screening methodology, diagnosis and management of gestational diabetes mellitus (GDM).

AIM

To evaluate routine practice for GDM management across the UK.

METHODS

Questionnaires were sent to all members of the Association of British Clinical Diabetologists. They were asked to describe how patients were screened for GDM, the diagnostic criteria and subsequent management and clinical targets. Centres that did not respond were followed up by personal communication. Variability trends within regions were assessed.

RESULTS

The response rate averaged 46% nationally (35-67%). Most (85%) units hold a joint clinic, regardless of the size. Most (82%) centres routinely screen for GDM; half universally and half screening high risk pregnancies only. Screening tests, cut-off values, timings and subsequent action vary widely. The first screening test to be used varies, with 40% using glycosuria, followed by random plasma glucose (RPG)(28%), high risk features (11%) then FPG in 6%. Cut-off values for both random and plasma glucose as screening methods also vary. The 75 g oral glucose tolerance test (OGTT) is the most likely confirmatory test to be used if initial screening is positive; however, clinicians rely on different cut-off values and timing. Most (95%) centres routinely assess foetal growth. Postpartum screening is undertaken by 90%, using a 75 g OGTT (93%). Most (90%) centres counsel patients about their high risk for further GDM and type 2 diabetes mellitus. Variability trends in any of the responses could not be detected between different regions in the UK.

CONCLUSION

Standards for GDM screening and management vary significantly across the UK. Although most centres utilize the 75 g OGTT to confirm the diagnosis, there is no consistency in its interpretation. This survey confirms the urgent need for consensus guideline development.

In-vitro analysis of the contribution of CYP2D6.35 to ultra-rapid metabolism

From 10 to 30% of CYP2D6 ultra-rapid metabolizers of Caucasian origin harbor alleles with duplicated or amplified functional CYP2D6 genes. Recently, the CYP2D6*35 allele has been reported to be more frequent in ultra-rapid metabolizing subjects than in extensive metabolizers, suggesting a possible role of this variant in CYP2D6 duplication-negative ultra-rapid metabolizing subjects. In this study, we examined the functional consequences of the Val11Met, Arg296Cys and Ser486Thr amino acid substitutions associated with the CYP2D6*35 on the expression and catalytic activity of the variant enzyme, heterologously expressed in yeast. Our results indicate that the functional activity and level of expression of recombinant CYP2D6.35 are comparable with those of the wild-type enzyme, thus precluding the hypothesis that the high level of enzyme activity in CYP2D6 duplication-negative ultra-rapid metabolizing subjects is a consequence of the expression of a more catalytically effective CYP2D6.35 enzyme.

Influence of phenylalanine-481 substitutions on the catalytic activity of cytochrome P450 2D6

Homology models of the active site of cytochrome P450 2D6 (CYP2D6) have identified phenylalanine 481 (Phe(481)) as a putative ligand-binding residue, its aromatic side chain being potentially capable of participating in pi-pi interactions with the benzene ring of ligands. We have tested this hypothesis by replacing Phe(481) with tyrosine (Phe(481)-->Tyr), a conservative substitution, and with leucine (Phe(481)-->Leu) or glycine (Phe(481)-->Gly), two non-aromatic residues, and have compared the properties of the wild-type and mutant enzymes in microsomes prepared from yeast cells expressing the appropriate cDNA-derived protein. The Phe(481)-->Tyr substitution did not alter the kinetics [K(m) (microM) and V(max) (pmol/min per pmol) respectively] of oxidation of S-metoprolol (27; 4.60), debrisoquine (46; 2.46) or dextromethorphan (2; 8.43) relative to the respective wild-type values [S-metoprolol (26; 3.48), debrisoquine (51; 3.20) and dextromethorphan (2; 8.16)]. The binding capacities [K(s) (microM)] of a range of CYP2D6 ligands to the Phe(481)-->Tyr enzyme (S-metoprolol, 22.8; debrisoquine, 12.5; dextromethorphan, 2.3; quinidine, 0.13) were also similar to those for the wild-type enzyme (S-metoprolol, 10.9; debrisoquine, 8.9; dextromethorphan, 3.1; quinidine, 0.10). In contrast, the Phe(481)-->Leu and Phe(481)-->Gly substitutions increased significantly (3-16-fold) the K(m) values of oxidation of the three substrates [S-metoprolol (120-124 microM), debrisoquine (152-184 microM) and dextromethorphan (20-31 microM)]. Similarly, the K(s) values of the ligands to Phe(481)-->Leu and Phe(481)-->Gly mutants were also increased 3 to 10-fold (S-metoprolol, 33.2-41.9 microM; debrisoquine, 85-90 microM; dextromethorphan, 15.7-18.8 microM; quinidine 0.35-0.53 microM). However, contrary to a recent proposal that Phe(481) has the dominant role in the binding of substrates that undergo CYP2D6-mediated N-dealkylation routes of metabolism, the Phe(481)-->Gly substitution did not substantially decrease the capacity of the enzyme to N-deisopropylate metoprolol (wild-type, 1.12 pmol/min per pmol of P450; Phe(481)-->Gly, 0.71), whereas an Asp(301)-->Gly substitution decreased the N-dealkylation reaction by 95% of the wild-type rate. Overall, our results are consistent with the proposal that Phe(481) is a ligand-binding residue in the active site of CYP2D6 and that the residue interacts with ligands via a pi-pi interaction between its phenyl ring and the aromatic moiety of the ligand. However, the relative importance of Phe(481) in binding is ligand-dependent; furthermore, its importance is secondary to that of Asp(301). Finally, contrary to predictions of a recent homology model, Phe(481) does not seem to have a primary role in CYP2D6-mediated N-dealkylation.

Evidence that serine 304 is not a key ligand-binding residue in the active site of cytochrome P450 2D6

Homology models of cytochrome P450 2D6 (CYP2D6) have identified serine 304 as an active-site residue and implicated a putative role for this residue in substrate enantioselectivity and the differential inhibition of enzyme activity by the diastereoisomers quinine and quinidine. The role of serine 304 in selectivity is thought to be achieved through a preferential hydrogen-bond interaction between the hydroxyl group of the residue and one of the stereoisomers of each ligand. We have tested this hypothesis by substituting serine 304 with alanine, a non-hydrogen-bonding residue, and compared the properties of the wild-type and mutant enzymes in microsomes prepared from yeast cells expressing the appropriate cDNA-derived enzyme. The Ser(304)Ala substitution did not alter the enantioselective oxidation of metoprolol; the O-demethylation reaction remained R-(+)-enantioselective (wild-type, R/S, 1.7; mutant, R/S, 1.6), whereas alpha-hydroxylation remained S-(-)-enantioselective (wild-type and mutant, R/S, 0.7). Similarly, the selective oxidation of the R-(+) and S-(-) enantiomers of propranolol to the major 4-hydroxy metabolite was identical with both wild-type and mutant forms of the enzyme (R/S 0.9), although the formation of minor metabolites (5-hydroxy and deisopropylpropranolol) did show some slight alteration in enantioselectivity. The differential inhibition of enzyme activity by quinine and quinidine was also identical with both forms of CYP2D6, the IC(50) values for each enzyme being approx. 10 microM and 0.1 microM for quinine and quinidine, respectively. The kinetics of formation of alpha-hydroxymetoprolol and 4-hydroxydebrisoquine by wild-type and the Ser(304)Ala mutant was also very similar. However, modest changes in the regioselective oxidation of metoprolol and debrisoquine were observed with the Ser(304)Ala mutant. The regio- and enantioselective oxidation of an analogue of metoprolol, in which the hydroxyl group attached to the chiral carbon was replaced by a methyl moiety, was again identical with both wild-type and Ser(304)Ala mutant. However, the observed selectivity was the reverse of that observed with metoprolol. Collectively, these data indicate that Ser(304) is unlikely to be a key ligand-binding residue, although the residue may indeed be located in the active-site cavity. The reversal of selectivity with the methyl analogue of metoprolol indicates that the hydroxyl group attached to the chiral centre of ligands, such as metoprolol, is important in defining the enzyme's selective properties, and that a hydrogen-bonding residue, other than Ser(304), may be involved in this interaction. Current homology models of the active site of CYP2D6 that predict a hydrogen-bond interaction between Ser(304) and specific ligands will need to be re-evaluated, and other candidate residues capable of such an interaction nominated and tested by site-directed mutagenesis studies.

Frequency of day residue in dreams of young adults

The percentage of dreams with day residue that could be identified by the dreamer, without free associating to the dream, was observed for a sample of 44 men and 44 women college students. The men identified day residue in 46.6% of their dreams and the women identified day residue in 48.9% of their dreams. The results were discussed in the context of Freud's idea that, while every dream likely has day residue, only some dreams have residue that can be identified without first free associating to the dream.

Ambulatory practice variation in Maryland: implications for Medicaid cost management

Simulation modeling with data from the Maryland Medicaid Management Information System has provided an opportunity to examine policy options and assess their likely impact on savings before program decisions were made. Analysis of a large sample of the Maryland Aid to Families with Dependent Children (AFDC) Medicaid subpopulation confirms that a significant difference in utilization and cost to Medicaid exists between usual sources of care for AFDC clients even after controlling for patient demographics and case-mix differences. Findings indicate that savings from reduced use of hospital outpatient departments may offset increases of as much as 40-50 percent in physician fees under certain assumptions.

The urinary excretion of catecholamines and their derivatives in primary hypertension in man

1. The 24 h urinary excretion of adrenaline, noradrenaline, normetadrenaline, metadrenaline and vanilloylmandelic acid has been compared in 17 male normotensive subjects and 25 age-matched male hypertensive patients studied under similar in-patient conditions. 2. 24 h urinary metadrenaline was significantly lower in the hypertensive patients. With this exception, no significant differences were found between the two groups when the total 24 h excretion of free catecholamines and their metabolites was analysed. 3. Diurnal variation in free catecholamine excretion was found in both normotensive and hypertensive subjects. There was no corresponding variation in metabolite excretion. 4. No correlation could be established between systolic or diastolic blood pressure and the amounts of the catecholamines or their metabolites in the urine of either group. 5. The results are considered in the light of recent work demonstrating high plasma catecholamine concentrations in hypertension. They lend no support to the concept that excessive circulating catecholamines are responsible for the elevated blood pressure in essential hypertension.