Consensus on the definitions and descriptions of the domains of the OMERACT Core Outcome Set for shared decision making interventions in rheumatology trials

OBJECTIVE

To gain consensus on the definitions and descriptions of the domains of the Outcome Measures in Rheumatology (OMERACT) core domain set for rheumatology trials evaluating shared decision making (SDM) interventions.

METHODS

Following the OMERACT Handbook methods, our Working Group (WG), comprised of 90 members, including 17 patient research partners (PRPs) and 73 clinicians and researchers, had six virtual meetings in addition to email exchanges to develop draft definitions and descriptions. The WG then conducted an international survey of its members to gain consensus on the definitions and descriptions. Finally, the WG members had virtual meetings and e-mail exchanges to review survey results and finalize names, definitions and descriptions of the domains.

RESULTS

WG members contributed to developing the definitions. Fifty-two members representing four continents and 13 countries completed the survey, including 15 PRPs, 33 clinicians and 37 researchers. PRPs and clinicians/researchers agreed with all definitions and descriptions with agreements ranging from 87% to 100%. Respondents suggested wording changes to the names, definitions and descriptions to better reflect the domains. Discussions led to further simplification and clarification to address common questions/concerns about the domains.

CONCLUSION

Our WG reached consensus on the definitions and descriptions of the domains of the core domain set for rheumatology trials of SDM interventions. This step is crucial to understand each domain and provides the foundation to identify instruments to measure each domain for inclusion in the Core Outcome Measurement Set.

CLINICAL SIGNIFICANCE

The current study provides consensus-based definitions and descriptions for the domains of the OMERACT core domain set for shared decision making interventions from patients/caregivers, clinicians and researchers. This is a crucial step to understand each domain and provides the foundation to identify instruments to measure each domain for inclusion in the Core Outcome Measurement Set for trials of SDM interventions.

Childhood cumulative trauma, social support and stress as predictors of illness outcomes and quality of life in bipolar disorder

OBJECTIVE

Trauma, social support and stress have been identified as factors which may be associated with the bipolar disorder illness course. However, these are yet to be examined in prospective studies as predictors of illness outcomes and overall quality of life in bipolar disorder.

METHOD

One hundred and fourteen participants (N = 97; 85.1% female) living with bipolar disorder I (41.2%) or II (58.8%) completed a semi-structured interview and a range of self-report measures assessing trauma history, social support, perceived stress, depression, anxiety, mania, suicidality, number of mood episodes and quality of life, at baseline and 6-month follow-up.

RESULTS

Childhood cumulative trauma, social support and perceived stress accounted for a substantial and significant portion of the variance in quality of life (62%; 23.6%), anxiety severity (34.6%; 24.5%) and depression severity (49.6%; 26.7%), at both baseline and 6-month follow-up. Perceived stress made significant unique contributions to the prediction of all outcomes, and social support made significant unique contributions to depression and quality of life in bipolar disorder.

CONCLUSION

Stress and social support play an important role in bipolar disorder and in quality of life for people living with this condition. Given that stress and social support are modifiable risk factors, this provides a promising direction for future intervention-based research.

Bipolar disorder and cumulative trauma: A systematic review of prevalence and illness outcomes

BACKGROUND

The experience of cumulative trauma may be common in bipolar disorder (BD). However, it is not frequently reported as most studies focus on childhood trauma without examining differences in the amount of trauma experienced. This systematic review aimed to determine the prevalence of lifetime cumulative trauma in BD as well as explore associated illness outcomes.

METHODS

A systematic review was completed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Both the prevalence and outcomes of cumulative trauma in BD were assessed. Five electronic databases were searched (Embase, MEDLINE, PsycINFO, Web of Science, and PTSD Pubs) for records from January 2010 until December 2022.

RESULTS

A total of 20 studies, with 9304 participants were included in the narrative synthesis. At least one-third of BD participants had experienced cumulative trauma, with a prevalence range from 29% to 82%. The main outcomes associated with a history of cumulative trauma were earlier age of onset, longer episode duration, more lifetime mood episodes, greater likelihood of experiencing psychotic features, and higher likelihood of past suicide attempts.

LIMITATIONS

This review has been limited by the lack of studies directly assessing cumulative trauma in BD.

CONCLUSIONS

Cumulative trauma is prevalent in BD. Preliminary evidence indicates an association with a range of adverse outcomes, emphasizing the need for clinicians to obtain a detailed trauma history and to consider these risks in the management of the disorder. Future studies should report on the prevalence of cumulative trauma, particularly in adulthood as this area remains unexplored.

Prevalence, Severity, and Measures of Anxiety in Rheumatoid Arthritis: A Systematic Review

OBJECTIVE

Many studies have reported high rates of anxiety in adults with rheumatoid arthritis (RA). The aim of this systematic review was to examine those findings and determine the overall prevalence, severity, and commonly used measures of anxiety in individuals with RA.

METHODS

Six databases were searched from January 2000 without restrictions on language/location, study design, or gray literature. All identified studies that examined anxiety prevalence and severity in adults with RA, as assessed with clinical diagnostic interview and/or standardized self-report measures, were considered for inclusion. Quality assessment of included studies was conducted using a modified Newcastle-Ottawa Evaluation Scale, and the findings were synthesized via a narrative approach.

RESULTS

Across the 47 studies (n = 11,085 participants), the sample size ranged from 60 to 1,321 participants with seven studies including healthy controls or groups with other health conditions. The studies were conducted across 23 countries, and anxiety prevalence ranged from 2.4% to 77%, predominantly determined with standardized self-report measures, of which Hospital Anxiety and Depression scale was used most frequently; only eight studies used a clinical diagnostic interview to confirm a specific anxiety diagnosis. Notable associations with anxiety in RA were physical disability, pain, disease activity, depression, and quality of life.

CONCLUSION

The reported prevalence of anxiety in RA varied widely potentially because of use of different self-report measures and cutoff points. Such cutoff points will need to be standardized to clinical thresholds to inform appropriate interventions for anxiety comorbidity in RA.

Social and Occupational Functioning in Individuals With BPD: A Systematic Review

This systematic review aimed to explore social and occupational functioning levels in individuals with BPD and whether this varies according to symptomatic status, age, or gender. A multi-database search was conducted for articles, and of the 1164 records identified, 19 were included in this review. Of the 15 studies reporting on social functioning, 13 indicated significant levels of impairment, and of the 14 studies reporting on global functioning, all indicated significant impairment across both clinical and in-remission populations. Occupational functioning was primarily assessed as either a part of global functioning or by subscales within social functioning, highlighting a lack of use of dedicated measures for its assessment. This systematic review found that individuals with BPD experience a range of significant impairments in functioning persisting across the lifespan. Further studies are warranted to explore levels of functional impairment across all functional domains and factors associated with continual functional impairment in this population.

Barriers to the use of exposure therapy by psychologists treating anxiety, obsessive-compuslive disorder, and posttraumatic stress disorder in an Australian sample

BACGROUND

Exposure therapy is a core component of the evidence-based treatment of anxiety, obsessive-compulsive disorder (OCD), and posttraumatic stress disorder (PTSD). Despite this, many clinicians fail to use exposure therapy in clinical practice, with research highlighting a number of potential barriers. Those findings raise serious concerns regarding the effective dissemination and delivery of evidence-based treatments that in turn have a major impact on client care and cost-effectiveness of psychological interventions.

AIMS

The present study aims to examine barriers to the use of exposure therapy in the clinical practice of Australian psychologists treating anxiety, OCD and PTSD.

METHOD

One hundred registered psychologists, aged between 23 and 71 years and 84% female, participated in this study via online survey.

RESULTS

Results suggest that the most common barriers to the use of exposure therapy include lack of confidence, negative beliefs about exposure therapy, insufficient underpinning theoretical knowledge, client-specific barriers, and logistical limitations.

CONCLUSIONS

Future research may further examine those barriers and the components of additional training and supervision that can increase the uptake of exposure therapy, particularly in clinical areas where it is a gold standard of practice.

Systematic assessment of the quality and integrity of popular mental health smartphone apps using the American Psychiatric Association's app evaluation model

Mobile phones are playing an increasingly important role in supporting mental health, by providing confidential, accessible and scalable support for individuals who may not seek or have means of accessing professional help. There are concerns, however, that many apps claiming to support mental health do not meet professional, ethical or evidence-based standards. App store search algorithms favour popularity (reviews and downloads) and commercial factors (in-app purchases), with what appears to be low prioritisation of safety or effectiveness features. In this paper, the most visible 100 apps for “depression”, “anxiety” and/or “mood” on the Google Play and Apple App stores were selected for assessment using the American Psychiatric Association App Evaluation model. This model systematically assesses apps across five broad steps: accessibility, integrity, clinical and research evidence base, user engagement and interoperability. Assessment is hierarchical, with the most fundamental requirements of apps assessed first, with apps excluded at each step if they do not meet the criteria. The relationship between app quality and app store visibility was first analysed. App quality was also compared across four different app function types: mental health promotion or psychoeducation; monitoring or tracking; assessment or prevention; and intervention or treatment. Of the 92 apps assessed (after eight failed to meet inclusion criteria), half failed to meet the first criterion step of accessibility, and a further 20% of the remaining apps failed to meet the second criterion step of security and privacy. Only three of the 10 apps most visible on app stores met the criteria for research/clinical base and engagement/ease of use, and only one app fulfilled all five criterion steps of the evaluation model. Quality did not differ significantly across app function type. There was no significant correlation between app quality and app store visibility, which presents a potential risk to vulnerable consumers. The findings of this review highlight the need for greater accountability of app developers to meet, and report, at least minimum quality and integrity standards for their apps. Recommendations are also provided to assist users and clinicians to make informed choices in their selection of reputable and effective mental health apps.

The Moderating Effect of Treatment Engagement on Fear-avoidance Beliefs in People With Chronic Low Back Pain

OBJECTIVES

The fear-avoidance model (FAM) is used to explain pain-related disability and design targeted interventions for people with chronic low back pain. While treatment engagement is critical, it is unknown how treatment moderates the FAM.

METHODS

This study examined whether pathways within the FAM were moderated by treatment engagement in 508 people with chronic low back pain. Measures of disability, pain, fear, catastrophizing, anxiety, depression, and self-efficacy were collected through self-report, and descriptors of treatment engaged within the last month (physical activity type, medication, allied and medical health practitioner). Moderated mediation analyses were performed to examine the conditional effect of treatment engagement on fear-avoidance pathways.

RESULTS

The conditional effect of anxiety on disability was only significant for people who did not report any treatment engagement in the last month (B=1.03, 95% confidence interval: 0.53-1.53, P<0.001). The effect of depression increased for people reporting more different types of treatment in the last month (1 level of treatment increase, B=0.27, 95% confidence interval: 0.05-0.50, P=0.019). Conversely, greater treatment engagement had a positive influence on the mediating effect of self-efficacy. That is, the effect of pain on efficacy reduced with greater treatment engagement, with a concomitant increased effect of self-efficacy on disability.

DISCUSSION

Clinicians should explore the history and rationale behind patient treatment seeking behavior to ensure this is not reinforcing the negative effects of depressive symptoms on pain-related disability.

Utilisation and predictors of use of exposure therapy in the treatment of anxiety, OCD and PTSD in an Australian sample: a preliminary investigation

BACKGROUND

Cognitive-behavior therapy (CBT) is known to be an effective treatment for the anxiety and related disorders, with exposure therapy being a key component of this treatment package. However, research on the use of exposure therapy in clinical practice has presented mixed results, potentially due to differences in samples and training programs across countries. The present study aimed to extend upon existing research by examining the use and predictors of use of exposure therapy in a sample of psychologists working in clinical practice in Australia who treat clients with an anxiety disorder, obsessive compulsive disorder (OCD) or post-traumatic stress disorder (PTSD).

METHODS

One hundred registered psychologists (M_age = 40.60; SD = 10.78; range 23 to 71 years; 84% female) participated in an online study investigating their clinical practices.

RESULTS

Results suggested that while the general use of exposure therapy is high, the use of disorder specific techniques was considerably lower, particularly for anxiety disorders and PTSD but not OCD. Psychology registration status and level of training were positively associated with use of exposure therapy as was the experience in treating anxiety disorders.

CONCLUSIONS

These findings suggest that further or ongoing professional training may be required to optimize the use of disorder specific techniques.

Endorsement of the OMERACT core domain set for shared decision making interventions in rheumatology trials: Results from a multi-stepped consensus-building approach

OBJECTIVE

To gain consensus on the Outcome Measures in Rheumatology (OMERACT) core domain set for rheumatology trials of shared decision making (SDM) interventions.

METHODS

The process followed the OMERACT Filter 2.1 methodology, and used consensus-building methods, with patients involved since the inception. After developing the draft core domain set in previous research, we conducted five steps: (i) improving the draft core domain set; (ii) developing and disseminating white-board videos to promote its understanding; (iii) conducting an electronic survey to gather feedback on the draft core domain set; (iv) finalizing the core domain set and developing summaries, a plenary session video and discussion boards to promote its understanding; and (v) conducting virtual workshops with voting to endorse the core domain set.

RESULTS

A total of 167 participants from 28 countries answered the survey (62% were patients/caregivers). Most participants rated domains as relevant (81%-95%) and clear (82%-93%). A total of 149 participants (n = 48 patients/caregivers, 101 clinicians/researchers) participated in virtual workshops and voted on the proposed core domain set which received endorsement by 95%. Endorsed domains are: 1- Knowledge of options, their potential benefits and harms; 2- Chosen option aligned with each patient's values and preferences; 3- Confidence in the chosen option; 4- Satisfaction with the decision-making process; 5- Adherence to the chosen option and 6- Potential negative consequences of the SDM intervention.

CONCLUSION

We achieved consensus among an international group of stakeholders on the OMERACT core domain set for rheumatology trials of SDM interventions. Future research will develop the Core Outcome Measurement Set.

CLINICAL SIGNIFICANCE

Prior to this study, there had been no consensus on the OMERACT core domain set for SDM interventions. The current study shows that the OMERACT core domain set achieved a high level of endorsement by key stakeholders, including patients/caregivers, clinicians and researchers.

Parental and partner role functioning and personal recovery in bipolar disorder

OBJECTIVES

Bipolar disorder research has primarily focused on clinical outcomes but there is increasing understanding of the importance of personal recovery. This study aimed to explore the relationship between functioning in key social roles including parenting and intimate relationships with personal recovery.

METHOD

Participants with bipolar disorder (N = 393) were recruited to participate in an online survey. Participants provided clinical information and completed measures of personal recovery, parental and intimate relationship functioning.

RESULTS

Parental functioning and intimate relationship functioning were found to be significantly associated with recovery scores with higher scores being associated with greater recovery. Parental functioning was also found to have a predictive effect, with higher parental functioning predicting greater recovery scores.

CONCLUSIONS

This study suggests that greater parental functioning may have an important role in the experience of personal recovery for people living with bipolar disorder. Future studies should further assess how supporting parenting may contribute recovery outcomes.

Correction to: Transdiagnostic group cognitive behaviour therapy for anxiety in bipolar disorder-a pilot feasibility and acceptability study

An amendment to this paper has been published and can be accessed via the original article.

An integrative collaborative care model for people with mental illness and physical comorbidities

BACKGROUND

Many individuals with mental health problems have comorbid physical conditions, or may present with substance/alcohol misuse or abuse issues. This results in complex treatment challenges that may not be adequately addressed by a model of care that is solely delivered by an individual clinician using a sole intervention. Mainstream pharmacotherapeutic treatment of mental health problems often have limited effectiveness in completely resolving symptoms, and may cause adverse side effects. Adjunctive treatment approaches, including nutraceuticals, lifestyle and behaviour change interventions, are widely used to assist with treatment of mental health problems. However, whilst these can be generally safer with fewer side effects, they have varying levels of evidentiary support. These circumstances warrant reframing the current treatment approach towards a more evidence-based integrative model which may better address the real-world challenges of psychiatric disorders and comorbid physical conditions. In essence, this means developing an integrative model of care which embodies an evidence-informed, personalized stepwise approach using both conventional pharmacological treatments alongside novel adjunctive treatments (where applicable) via the application of a collaborative care approach.

DISCUSSION

In order to inform this position, a brief review of findings on common patterns of comorbidity in mental illness is presented, followed by identification of limitations of conventional treatments, and potential applications of integrative medicine interventions. Advantages and challenges of integrative mental health care, collaborative models of care, review of research highlights of select integrative approaches, and comment on potential cost advantages are then discussed. We propose that a collaborative care model incorporating evidence-based integrative medicine interventions may more adequately address mental health problems with comorbid medical conditions. Robust research is now required of such a model, potentially within an integrative clinical practice.

Transdiagnostic group cognitive behaviour therapy for anxiety in bipolar disorder-a pilot feasibility and acceptability study

Objective

Anxiety is prominent for many people living with bipolar disorder, yet the benefit of psychological interventions in treating this co-morbidity has been minimally explored and few studies have been conducted in a group format. This study aimed to assess the feasibility and acceptability of a transdiagnostic cognitive behaviour therapy group anxiety programme (CBTA-BD) for people living with bipolar disorder.

Methods

Participants were recruited to take part in a 9-week group therapy programme designed to treat anxiety in bipolar disorder using cognitive behaviour therapy. They were assessed by structured interview (SCID-5 RV) to confirm the diagnosis of bipolar disorder and assessed for anxiety disorders. Self-report questionnaires—DASS (depression, anxiety, stress), ASRM (mania), STAI (state and trait anxiety) and Brief QOL.BD (quality of life) pre- and post-treatment were administered.

Results

Fourteen participants enrolled in the programme, with 10 participants (5 male; 5 female) completing the follow-up assessments. Two groups (one during working hours, the other outside working hours) were conducted. The programme appeared acceptable and feasible with a mean of 6.9 (77%) sessions attended, though five (50%) participants completed less than 3 weeks homework.

Conclusion

The transdiagnostic cognitive behaviour therapy group anxiety programme (CBTA-BD) proved feasible and acceptable for participants; however, homework compliance was poor. A larger randomised pilot study is needed to assess the benefits of the intervention on symptom measures and address homework adherence, possibly through providing support between sessions or tailoring it more specifically to participant needs.

"Finding my own identity": a qualitative metasynthesis of adult anorexia nervosa treatment experiences

Background

The aim of this metasynthesis was to explore adult anorexia nervosa (AN) treatment experiences, including facilitators and barriers to treatment engagement and ways that questions of identity and personal agency were negotiated in treatment contexts.

Methods

From 14 qualitative studies that met the search criteria, this thematic synthesis analyzed the sensitized concept of identity in the participants’ experiences of AN treatments, including their sense of personal agency, and implications for their recovery. The study was registered with Prospero (ID: CRD42018089259) and is reported according to PRISMA guidelines.

Results

Three meta-themes were generated with the following key findings: grappling with identity, where collaborative and tailored interventions were positively experienced; the quality of the therapeutic relationship, which existed in a recursive relationship; and, rebuilding identity that included therapists standing with the person in recovering a sense of identity outside the anorexic identity. Importantly, interventions that failed to be negotiated with the person were experienced as disempowering however, where a two-way trust existed in the therapeutic relationship, it critically empowered and shaped participants’ sense of identity, and broadened the perception that they were valuable as a person.

Conclusions

There was consensus across the range of treatment contexts that individuals with a lived AN experience preferred treatments where they experienced (1) a sense of personal agency through tailored interventions; and (2) therapists who treated them as a person who, in the face of their struggles, had skills and capacities in the processes of recovering and rebuilding sustainable and preferred identities outside the AN identity.

Psychological distress among carers and the moderating effects of social support

BACKGROUND

Carers provide both practical and emotional support and often play an important role in coordination of care for recipients. The demands of caring may lead to increased levels of stress for the carer, which can affect mental health and quality of life. This study examined the relationship between being a carer and psychological distress (assessed using the Kessler Psychological Distress Scale [K10]), and explored the moderating effect of social support in that relationship using a large sample.

METHODS

The study used data from the 45 and Up study, a large cohort study of individuals aged 45 years and over in New South Wales, Australia, and applied multiple regression methods and moderation analysis. The sample for the current study comprised 267,041 participants drawn from the baseline dataset, with valid data on the primary outcome (carer status).

RESULTS

The mean age of participants was 62.73 (±11.18) years, and 4.23% and 7.13% were identified as full-time and part-time carers, respectively. Compared to non-carers, full-time carers had K10 scores that were on average, higher by 1.87, while part-time carers' K10 scores were on average higher by 1.60 points. A perception of social support reduced the strength of the relationship between carer status and psychological distress by 40% for full-time carers and 60% for part-time carers.

CONCLUSIONS

The findings have important implications, for both prevention and treatment of psychological problems among carers. In terms of prevention, they suggest that public health campaigns focused on increasing awareness regarding the psychological burden faced by carers would be useful. In terms of intervention, potential treatments that focus on improving social support networks may be helpful. The results are particularly important in the current context of an ageing population in Australian and other developed countries, where caregiving is likely to play an increasing role in the care and support services.

Young People's Response to Six Smartphone Apps for Anxiety and Depression: Focus Group Study

BACKGROUND

Suicide is one of the most frequent causes of death in young people worldwide. Depression lies at the root of this issue, a condition that has a significant negative impact on the lives of those who experience it and on society more generally. However, 80% of affected young people do not obtain professional help for depression and other mental health issues. Therefore, a key challenge is to find innovative and appealing ways to engage young people in learning to manage their mental health. Research suggests that young people prefer to access anonymous Web-based programs rather than get face-to-face help, which has led to the development of numerous smartphone apps. However, the evidence indicates that not all of these apps are effective in engaging the interest of young people who are most in need of help.

OBJECTIVE

The study aimed to investigate young people's response to six currently available smartphone apps for mental health and to identify features that young people like and dislike in such apps.

METHODS

Focus groups were conducted with 23 young people aged 13 to 25 years in which they viewed and used six smartphone apps for mental health. A general inductive approach following a realist paradigm guided data analysis.

RESULTS

The results revealed that young people value autonomy and the opportunity to personalize experiences with these apps above other things. Finding a balance between simplicity and informativeness is also an important factor.

CONCLUSIONS

App developers need to consider using participant-design frameworks to ensure that smartphone apps are providing what young people want in a mental health app. Solutions to the need for personalization and increasing user engagement are also crucially needed.

Depression, mania and self-reported creativity in bipolar disorder

The present study investigated the relationship between self-reported creativity and current symptoms of depression and mania. Three hundred and ninety-seven participants previously diagnosed with BD completed an online questionnaire that included demographic and clinical information questions, creativity and self-report measures of depression and hypo/mania over the past week. Those reporting clinically significant depressive symptoms had significantly lower creativity scores than those in the hypo/mania and no current symptom groups. There were no significant differences between those reporting clinically significant hypo/mania and no current symptom groups, however they reported significantly higher creativity scores than those who reported symptoms of both hypo/mania and depression in the past week. Furthermore, subscales of the creativity measure demonstrated significant differences between some of the groups on the drama, interaction and maths/science subscales. These findings suggest that there is a relationship between mood and how people with BD understand and experience creativity. Further research is needed to better understand the role of creativity in the management of bipolar disorder and how this may be associated with well-being outcomes such as recovery, and also how it may be incorporated into treatment.

The relationship between social support and personal recovery in bipolar disorder

OBJECTIVE

Mood symptoms may impact on personal recovery and psychosocial functioning in bipolar disorder (BD). This study aimed to explore whether recent mood symptoms were associated with recovery and social support from friends, family, and partners.

METHOD

A cross-sectional survey was conducted with 312 participants who self-reported a confirmed diagnosis of BD and were recruited through social media.

RESULTS

A series of one-way analyses of variance (ANOVA) were conducted. Those who reported depression (52%) or hypo/mania (47%) reported lower recovery scores. Those who reported seeing family and >1 friend reported higher recovery scores along with those who were employed, did not receive benefits, and had higher education. Recent hypo/mania symptoms were associated with less family contact.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Friends and family may be conducive to recovery, however recent symptoms may have an impact. More research is required to understand how hypo/mania symptoms may influence accessing family support. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

OMERACT Development of a Core Domain Set of Outcomes for Shared Decision-making Interventions

OBJECTIVE

The Outcome Measures in Rheumatology (OMERACT) Shared Decision Making (SDM) Working Group aims to determine the core outcome domain set for measuring the effectiveness of SDM interventions in rheumatology trials.

METHODS

A white paper was developed to clarify the draft core domain set. It was then used to prepare for interviews to investigate reasons for lack of consensus on it and to suggest further improvements.

RESULTS

OMERACT scientists/clinicians (n = 13) and patients (n = 10) suggested limiting the core domain set to outcome domains, removing process domains, and clarifying remaining domains.

CONCLUSION

A revised core domain set will undergo further consensus-building.

What Works and What Doesn't Work? A Systematic Review of Digital Mental Health Interventions for Depression and Anxiety in Young People

Background: A major challenge in providing mental health interventions for young people is making such interventions accessible and appealing to those most in need. Online and app-based forms of therapy for mental health are burgeoning. It is therefore crucial to identify features that are most effective and engaging for young users. Objectives: This study reports a systematic review and meta-analysis of digital mental health interventions and their effectiveness in addressing anxiety and depression in young people to determine factors that relate to outcomes, adherence, and engagement with such interventions. Methods: A mixed methods approach was taken, including a meta-analysis of 9 randomized controlled trials that compared use of a digital intervention for depression in young people to a no-intervention control group, and 6 comparing the intervention to an active control condition. A thematic analysis and narrative synthesis of 41 studies was also performed. Results: The pooled effect size of digital mental health interventions on depression in comparison to a no-intervention control was small (Cohen's d = 0.33, 95% CI 0.11 to 0.55), while the pooled effect size of studies comparing an intervention group to an active control showed no significant differences (Cohen's d = 0.14, 95% CI -.04 to 0.31). Pooled effect sizes were higher when supervision was involved (studies with no-intervention controls: Cohen's d = 0.52, 95% CI 0.23 to 0.80; studies with active control: Cohen's d = 0.49, 95% CI -0.11, 1.01). Engagement and adherence rates were low. Qualitative analysis revealed that users liked interventions with a game-like feel and relatable, interactive content. Educational materials were perceived as boring, and users were put off by non-appealing interfaces and technical glitches. Conclusions: Digital interventions work better than no intervention to improve depression in young people when results of different studies are pooled together. However, these interventions may only be of clinical significance when use is highly supervised. Digital interventions do not work better than active alternatives regardless of the level of support. Future interventions need to move beyond the use of digital educational materials, considering other ways to attract and engage young people and to ensure relevance and appeal.

Emotional speech processing deficits in bipolar disorder: The role of mismatch negativity and P3a

BACKGROUND

Deficits in emotional prosody processing have been observed in bipolar disorder (BD). While recent neural studies have explored impaired processing of facial expressions, little is known about deficits in emotional speech processing, or the specific stages of processing at which they occur. This study examined if pre-attentive detection and attention to emotional speech is impaired in BD, relative to healthy individuals.

METHODS

The EEG data was collected from 14 individuals with BD and 14 healthy control (HC) participants while the auditory stimuli was presented via a passive three-stimulus oddball sequence which included emotionally (neutral, happy, sad) spoken syllables and acoustically matched nonvocal tones. Event-related potentials (ERPs) were evaluated in terms of Mismatch Negativity (MMN) and P3a (event-related potentials signals).

RESULTS

Individuals with BD showed normal MMN amplitude, but significantly delayed MMN latency and reduced P3a amplitude in response to the emotional syllables compared to HC.

LIMITATIONS

Small sample size, lack of control of psychopharmacological intervention and no inclusion of an affective prosody-labelling task.

CONCLUSIONS

The finding that changes in emotional speech prosody in the pre-attentive stages of processing (MMN) were unimpaired in individuals with BD; while automatic orientation towards emotionally salient speech (P3a) was reduced compared to HC, suggests that vocal emotional cues may not be recognised as salient by individuals with BD, resulting in fewer attentional resources allocation to further processing. This may lead to poorer integration of auditory emotional cues and other sensory information and negatively impact interpersonal and psychosocial functions.

Sex-specific relevance of diabetes to occlusive vascular and other mortality: a collaborative meta-analysis of individual data from 980 793 adults from 68 prospective studies

BACKGROUND

Several studies have shown that diabetes confers a higher relative risk of vascular mortality among women than among men, but whether this increased relative risk in women exists across age groups and within defined levels of other risk factors is uncertain. We aimed to determine whether differences in established risk factors, such as blood pressure, BMI, smoking, and cholesterol, explain the higher relative risks of vascular mortality among women than among men.

METHODS

In our meta-analysis, we obtained individual participant-level data from studies included in the Prospective Studies Collaboration and the Asia Pacific Cohort Studies Collaboration that had obtained baseline information on age, sex, diabetes, total cholesterol, blood pressure, tobacco use, height, and weight. Data on causes of death were obtained from medical death certificates. We used Cox regression models to assess the relevance of diabetes (any type) to occlusive vascular mortality (ischaemic heart disease, ischaemic stroke, or other atherosclerotic deaths) by age, sex, and other major vascular risk factors, and to assess whether the associations of blood pressure, total cholesterol, and body-mass index (BMI) to occlusive vascular mortality are modified by diabetes.

RESULTS

Individual participant-level data were analysed from 980 793 adults. During 9·8 million person-years of follow-up, among participants aged between 35 and 89 years, 19 686 (25·6%) of 76 965 deaths were attributed to occlusive vascular disease. After controlling for major vascular risk factors, diabetes roughly doubled occlusive vascular mortality risk among men (death rate ratio [RR] 2·10, 95% CI 1·97-2·24) and tripled risk among women (3·00, 2·71-3·33; χ2 test for heterogeneity p<0·0001). For both sexes combined, the occlusive vascular death RRs were higher in younger individuals (aged 35-59 years: 2·60, 2·30-2·94) than in older individuals (aged 70-89 years: 2·01, 1·85-2·19; p=0·0001 for trend across age groups), and, across age groups, the death RRs were higher among women than among men. Therefore, women aged 35-59 years had the highest death RR across all age and sex groups (5·55, 4·15-7·44). However, since underlying confounder-adjusted occlusive vascular mortality rates at any age were higher in men than in women, the adjusted absolute excess occlusive vascular mortality associated with diabetes was similar for men and women. At ages 35-59 years, the excess absolute risk was 0·05% (95% CI 0·03-0·07) per year in women compared with 0·08% (0·05-0·10) per year in men; the corresponding excess at ages 70-89 years was 1·08% (0·84-1·32) per year in women and 0·91% (0·77-1·05) per year in men. Total cholesterol, blood pressure, and BMI each showed continuous log-linear associations with occlusive vascular mortality that were similar among individuals with and without diabetes across both sexes.

INTERPRETATION

Independent of other major vascular risk factors, diabetes substantially increased vascular risk in both men and women. Lifestyle changes to reduce smoking and obesity and use of cost-effective drugs that target major vascular risks (eg, statins and antihypertensive drugs) are important in both men and women with diabetes, but might not reduce the relative excess risk of occlusive vascular disease in women with diabetes, which remains unexplained.

FUNDING

UK Medical Research Council, British Heart Foundation, Cancer Research UK, European Union BIOMED programme, and National Institute on Aging (US National Institutes of Health).

Relational spirituality and quality of life 2007 to 2017: an integrative research review

BACKGROUND

Despite the increasing number of evidence-based research on relational spirituality (RS) and quality of life (QoL) in medical-health research, little is known about the links between RS and QoL outcomes and the mechanisms by which RS aspects are functionally tied to QoL.

OBJECTIVE

To determine how RS is perceived/positioned in relation to QoL, we (a) examined recent available data that identify and appraise the links between RS and QoL; (b) identified themes emerging from the association between RS and QoL, and (c) discussed the implications of the effects of RS on QoL outcomes.

METHODS

We conducted an integrative research review of English-language peer-reviewed articles published between 2007 to March 2017 which examined an association between RS and QoL, as identified from a search of three databases: PubMed, PsycINFO, and ScienceDirect.

RESULTS

A total of 20 studies were analysed. Of these, twelve (60%) reported positive association between RS and QoL, three (15%) studies reported inverse associations, whereas five (25%) studies showed evidence of lack of association (with two out of the five studies showing an indirect association). Physical health and psychological functioning were the most researched domains of QoL, and some studies suggest an attachment-based model of RS in the last 10 years of RS and QoL research. Studies conducted with participants with serious illnesses ranging from dementia, cardiac arrest, and breast cancer reported no association between RS and physical health. Our review shows evidence of both the direct and/or indirect effects of RS on QoL as a possible spiritual coping model for complementary alternative health therapy, albeit occurring through several religious-related psychosocial conduits.

CONCLUSION AND IMPLICATION

RS appears to be associated with health benefits as indicated across QoL domains. General medical practitioners and other healthcare agencies could benefit from the understanding that a spiritual coping model could aid their patients, and therefore their clinical practices, in the healing process.

Menopause and illness course in bipolar disorder: A systematic review

OBJECTIVES

Menopause may be a time of increased mood symptoms for some women. This systematic review aimed to examine the severity of symptoms and prevalence of mood changes in women with bipolar disorder during peri-menopause and post-menopause.

METHODS

A systematic review was undertaken in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The two primary outcomes assessed were relapse rates and symptom severity during menopause. Databases searched were MEDLINE, EMBASE, PsychInfo, CINAHL and SCOPUS from January 1980 until December 2016.

RESULTS

Nine studies, including a total of 273 participants diagnosed with bipolar disorder and who reported menopause, were included in the narrative synthesis. Menopause was reported to be associated with increased symptoms overall, and with depression in particular (range of 46%-91%). The collection of self-reported retrospective data was the most commonly used method to record menopause status.

CONCLUSIONS

The impact of menopause on illness course for women with bipolar disorder is largely under-explored. Preliminary evidence suggests that it may be associated with increased bipolar symptoms. Further work is needed to explore how menopause may interact with bipolar disorder over time and the nature of these symptom changes, and if and how menopause may differ from other reproductive stages.

Toward the Development of a Core Set of Outcome Domains to Assess Shared Decision-making Interventions in Rheumatology: Results from an OMERACT Delphi Survey and Consensus Meeting

OBJECTIVE

The aim of this Outcome Measures in Rheumatology (OMERACT) Working Group was to determine the core set of outcome domains and subdomains for measuring the effectiveness of shared decision-making (SDM) interventions in rheumatology clinical trials.

METHODS

Following the OMERACT Filter 2.0, and based on a previous literature review of SDM outcome domains and a nominal group process at OMERACT 2014, (1) an online Delphi survey was conducted to gather feedback on the draft core set and refine its domains and subdomains, and (2) a workshop was held at the OMERACT 2016 meeting to gain consensus on the draft core set.

RESULTS

A total of 170 participants completed Round 1 of the Delphi survey, and 116 completed Round 2. Respondents came from 29 countries, with 49% being patients/caregivers. Results showed that 14 out of the 17 subdomains within the 7 domains exceeded the 70% criterion (endorsement ranged from 83% to 100% of respondents). At OMERACT 2016, only 8% of the 96 attendees were patients/caregivers. Despite initial votes of support in breakout groups, there was insufficient comfort about the conceptualization of these 7 domains and 17 subdomains for these to be endorsed at OMERACT 2016 (endorsement ranged from 17% to 68% of participants).

CONCLUSION

Differences between the Delphi survey and consensus meeting may be explained by the manner in which the outcomes were presented, variations in participant characteristics, and the context of voting. Further efforts are needed to address the limited understanding of SDM and its outcomes among OMERACT participants.

Pain severity predicts depressive symptoms over and above individual illnesses and multimorbidity in older adults

BACKGROUND

Multi-morbidity in older adults is commonly associated with depressed mood. Similarly, subjective reports of pain are also associated with both physical illness and increased depressive symptoms. However, whether pain independently contributes to the experience of depression in older people with multi-morbidity has not been studied.

METHODS

In this study, participants were 1281 consecutive older adults presenting to one of 19 primary care services in Australia (recruitment rate = 75%). Participants were asked to indicate the presence of a number of common chronic illnesses, to rate their current pain severity and to complete the Geriatric Depression Scale.

RESULTS

Results confirmed that the number of medical illnesses reported was strongly associated with depressive symptoms. Twenty-six percent of participants with multi-morbidity scored in the clinical range for depressive symptoms in comparison to 15% of participants with no illnesses or a single illness. In regression analyses, the presence of chronic pain (t = 5.969, p < 0.0005), diabetes (t = 4.309, p < 0.0005), respiratory (t = 3.720, p < 0.0005) or neurological illness (t = 2.701, p = 0.007) were all independent contributors to depressive symptoms. Even when controlling for each individual illness, and the overall number of illnesses (t = 2.207, p = 0.028), pain severity remained an independent predictor of depressed mood (F change = 28.866, p < 0.0005, t = 5.373, p < 0.0005).

CONCLUSIONS

Physicians should consider screening for mood problems amongst those with multi-morbidity, particularly those who experience pain.

Clinical characteristics of women with reproductive cycle-associated bipolar disorder symptoms

OBJECTIVE

Although there is clear evidence that reproductive cycle events are associated with mood episodes for women with bipolar disorder, few studies have examined for relationships between these and specific clinical characteristics of the disorder. This study aimed to explore the relationship between mood symptoms associated with reproductive cycle events and features of the disorder indicative of a more severe lifetime course.

METHOD

Totally, 158 women of at least 18 years of age participated in the study. Subjects were recruited through a specialist clinic at the Black Dog Institute, Sydney, Australia.

RESULTS

In total, 77% of women reported increases in mood symptoms during perimenstrual, postnatal or menopausal periods. These women had an earlier age of onset for depressive and hypo/manic episodes and a greater likelihood of comorbid anxiety disorders, rapid cycling and mixed mood compared to those who did not report such reproductive cycle-associated mood changes. Women who experienced postnatal episodes were also more likely to experience worse mood symptoms perimenstrually and menopausally.

CONCLUSION

First, reproductive cycle event-related worsening of mood was associated with a more severe lifetime course of bipolar disorder, and, second, it appears that some women have a greater propensity to mood worsening at each of these reproductive cycle events. If replicated, these findings provide important information for clinicians treating women with reproductive cycle event mood changes and highlight the need for improved therapeutics for such presentations.

PARTNER INVOLVEMENT: NEGOTIATING THE PRESENCE OF PARTNERS IN PSYCHOSOCIAL ASSESSMENT AS CONDUCTED BY MIDWIVES AND CHILD AND FAMILY HEALTH NURSES

Universal screening for maternal depression and assessment of psychosocial risks has been integrated into the routine perinatal care provided in many Australian hospitals, but to date, partners/fathers have been largely excluded from the process. This study explored the ways in which clinicians in health service settings include partners who attend antenatal and postnatal visits with women. Qualitative data were collected using observations (n = 54), interviews (n = 60), and discussion groups (n = 7) with midwives and child and family health nurses who conducted the appointments. Transcripts from observations, interviews, and discussion groups underwent qualitative analysis, and key themes were identified. Results showed partners to have little or no involvement in psychosocial assessment and depression screening. Thematic analysis revealed four key themes: negotiating partner exclusion, partial inclusion, women's business or a couple concern? and they know anyway. Partner involvement appeared to be challenged particularly by mandatory interpersonal violence screening, which, according to health service policy, is to be conducted confidentially. Overall, results highlighted partner involvement in perinatal depression screening and psychosocial assessment processes and identified some of the benefits such as partner disclosure, but also the challenges and complexities of inclusion of partners. Clinical implications and directions for further education and research are discussed.

Gd(III) complexes as paramagnetic tags: Evaluation of the spin delocalization over the nuclei of the ligand

Complexes of the Gd(III) ion are currently being established as spin labels for distance determination in biomolecules by pulse dipolar spectroscopy. Because Gd(III) is an f ion, one expects electron spin density to be localized on the Gd(III) ion - an important feature for the mentioned application. Most of the complex ligands have nitrogens as Gd(III) coordinating atoms. Therefore, measurement of the (14)N hyperfine coupling gives access to information on the localization of the electron spin on the Gd(III) ion. We carried out W-band, 1D and 2D (14)N and (1)H ENDOR measurements on the Gd(III) complexes Gd-DOTA, Gd-538, Gd-595, and Gd-PyMTA that serve as spin labels for Gd-Gd distance measurements. The obtained (14)N spectra are particularly well resolved, revealing both the hyperfine and nuclear quadrupole splittings, which were assigned using 2D Mims ENDOR experiments. Additionally, the spectral contributions of the two different types of nitrogen atoms of Gd-PyMTA, the aliphatic N atom and the pyridine N atom, were distinguishable. The (14)N hyperfine interaction was found to have a very small isotropic hyperfine component of -0.25 to -0.37MHz. Furthermore, the anisotropic hyperfine interactions with the (14)N nuclei and with the non-exchangeable protons of the ligands are well described by the point-dipole approximation using distances derived from the crystal structures. We therefore conclude that the spin density is fully localized on the Gd(III) ion and that the spin density distribution over the nuclei of the ligands is rightfully ignored when analyzing distance measurements.

Adolescents' health-related quality of life (HRQoL) changes over time: a three year longitudinal study

BACKGROUND

Adolescence is a significant developmental stage marked by physical, psychological and social changes. While adolescents are generally perceived to be healthy, this stage of development is also associated with an emergence of risk factors that may have long-term consequences for their wellbeing. The aim of this study was to assess health related quality of life (HRQoL), and possible gender and age differences, in a sample of secondary school-aged adolescents over a three-year time period.

METHODS

Australian adolescents (n = 403, aged 12-15 at baseline) across six New South Wales high schools completed the KIDSCREEN-27 Questionnaire at three time points. The KIDSCREEN-27 measures five HRQoL domains (physical wellbeing, psychological wellbeing, autonomy and parents relations, social support and peers, and school environment). Mixed-between-within-subjects ANOVA analyses were employed to examine HRQoL over time and across age and gender.

RESULTS

HRQoL rates were comparable to the European-based KIDSCREEN norms with the exception of psychological wellbeing, which was considerably lower in this study's sample. Over time, for the total sample, there were significant changes on only one of the five dimensions (social support and peers). However, gender differences were found to be significant across three dimensions (physical wellbeing, psychological wellbeing, and autonomy and parents relations), with females reporting lower scores than males (i.e. lower HRQoL). Females' scores also declined over the three time points across two of the five HRQoL dimensions (social support and peers, and school environment), indicating reductions in HRQoL over time. Age differences were found across all but one dimension (autonomy and parents relations).

CONCLUSIONS

Although statistically significant, the changes in HRQoL may not be clinically significant, as the effect sizes were small and therefore those changes would not be readily noticeable. Those changes, however, suggest that, while HRQoL is predominantly stable over time, fluctuations and declines, such as those found for females, may be early indicators of physical and psychological vulnerabilities. If such vulnerabilities are detected timely; they may be addressed with preventative measures or appropriate interventions.

Problem-Solving Therapy Reduces Suicidal Ideation In Depressed Older Adults with Executive Dysfunction

OBJECTIVE

To test the hypothesis that Problem Solving Therapy (PST) is more effective than Supportive Therapy (ST) in reducing suicidal ideation in older adults with major depression and executive dysfunction. We further explored whether patient characteristics, such as age, sex, and additional cognitive impairment load (e.g., memory impairments) were related to changes in suicidal ideation over time.

DESIGN

Secondary data analysis using data from a randomized clinical trial allocating participants to PST or ST at 1:1 ratio. Raters were blind to patients' assignments.

SETTING

University medical centers.

PARTICIPANTS

221 people aged 65 years old and older with major depression determined by Structured Clinical Interview for DSM-III-R diagnosis and executive dysfunction as defined by a score of 33 or less on the Initiation-Perseveration Score of the Mattis Dementia Rating Scale or a Stroop Interference Task score of 25 or less.

INTERVENTIONS

12 weekly sessions of PST or ST.

MAIN OUTCOME MEASURES

The suicide item of the Hamilton Depression Rating Scale.

RESULTS

Of the 221 participants, 61% reported suicidal ideation (SI). The ST group had a lower rate of improvement in SI after 12 weeks (44.6%) than did the PST group (60.4%, Fisher's exact test p = 0.031). Logistic regression showed significantly greater reductions in SI in elders who received PST at both 12 weeks (OR: .50, Z = -2.16, p = 0.031) and 36 weeks (OR: 0.5, Z = -1.96, p = 0.05) after treatment.

CONCLUSIONS

PST is a promising intervention for older adults who are at risk for suicide. ClinicalTrials.gov Identifier: NCT00052091.

The motherhood choices decision aid for women with rheumatoid arthritis increases knowledge and reduces decisional conflict: a randomized controlled trial

BACKGROUND

For many women with Rheumatoid Arthritis (RA) motherhood decisions are complicated by their condition and complex pharmacological treatments. Decisions about having children or expanding their family require relevant knowledge and consultation with their family and physician as conception and pregnancy has to be managed within the RA context. Relevant information is not readily available to women with RA. Therefore a randomized controlled study was conducted to evaluate the effectiveness of a new motherhood decision aid (DA) developed specifically for women with RA.

METHODS

One hundred and forty-four women were randomly allocated to either an intervention or control group. All women completed a battery of questionnaires at pre-intervention, including, the Pregnancy in Rheumatoid Arthritis Questionnaire (PiRAQ), the Decisional Conflict Scale (DCS), the Hospital Anxiety and Depression Scale (HADS), and the Arthritis Self-Efficacy Scale (ASES), and provided basic demographic information. Women in the DA group were sent an electronic version of the DA, and completed the battery of questionnaires for a second time post-intervention.

RESULTS

Women who received the DA had a 13 % increase in relevant knowledge (PiRAQ) scores and a 15 % decrease in scores on the decisional conflict (DCS), compared to the control group (1 %, 2 % respectively). No adverse psychological effects were detected as evident in unchanged levels of depression and anxiety symptoms.

CONCLUSIONS

The findings of this study suggest that this DA may be an effective tool in assisting women with RA when contemplating having children or more children.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, http://www.anzctr.org.au/ , ACTRN12615000523505.

Health-related quality of life in a sample of Australian adolescents: gender and age comparison

PURPOSE

The primary purpose of this study was to profile the health-related quality of life (HRQoL) in a sample of secondary school-aged children in Australia. The secondary purpose was to contribute to the international literature on the HRQoL of adolescents using the KIDSCREEN instrument.

METHODS

The KIDSCREEN-27 Questionnaire was completed by 1111 adolescents aged between 11 and 17 from six Australian secondary schools. MANCOVA analysis was employed to examine age and gender differences.

RESULTS

Over 70 % of participants reported high levels of HRQoL across all five dimensions. Age patterns were identified with younger adolescents reporting greater HRQoL than older adolescents. Similarly, gender differences were noted with male adolescents reporting higher scores than female adolescents on three out of five dimensions of HRQoL.

CONCLUSIONS

This is the first study to measure HRQoL in Australian adolescents using the KIDSCREEN instrument. Consistent with previous research, gender and age differences were found across most dimensions of HRQoL. These results highlight the importance of comprehensively measuring the HRQoL in adolescents to capture developmental shifts and to inform preventative and supportive programs as needed.

Development of a Draft Core Set of Domains for Measuring Shared Decision Making in Osteoarthritis: An OMERACT Working Group on Shared Decision Making

OBJECTIVE

Despite the importance of shared decision making for delivering patient-centered care in rheumatology, there is no consensus on how to measure its process and outcomes. The aim of this Outcome Measures in Rheumatology (OMERACT) working group is to determine the core set of domains for measuring shared decision making in intervention studies in adults with osteoarthritis (OA), from the perspectives of patients, health professionals, and researchers.

METHODS

We followed the OMERACT Filter 2.0 method to develop a draft core domain set by (1) forming an OMERACT working group; (2) conducting a review of domains of shared decision making; and (3) obtaining opinions of all those involved using a modified nominal group process held at a session activity at the OMERACT 12 meeting.

RESULTS

In all, 26 people from Europe, North America, and Australia, including 5 patient research partners, participated in the session activity. Participants identified the following domains for measuring shared decision making to be included as part of the draft core set: (1) identifying the decision, (2) exchanging information, (3) clarifying views, (4) deliberating, (5) making the decision, (6) putting the decision into practice, and (7) assessing the effect of the decision. Contextual factors were also suggested.

CONCLUSION

We proposed a draft core set of shared decision-making domains for OA intervention research studies. Next steps include a workshop at OMERACT 13 to reach consensus on these proposed domains in the wider OMERACT group, as well as to detail subdomains and assess instruments to develop a core outcome measurement set.

Zero field splitting fluctuations induced phase relaxation of Gd3+ in frozen solutions at cryogenic temperatures

Distance measurements using double electron-electron resonance (DEER) and Gd(3+) chelates for spin labels (GdSL) have been shown to be an attractive alternative to nitroxide spin labels at W-band (95GHz). The maximal distance that can be accessed by DEER measurements and the sensitivity of such measurements strongly depends on the phase relaxation of Gd(3+) chelates in frozen, glassy solutions. In this work, we explore the phase relaxation of Gd(3+)-DOTA as a representative of GdSL in temperature and concentration ranges typically used for W-band DEER measurements. We observed that in addition to the usual mechanisms of phase relaxation known for nitroxide based spin labels, GdSL are subjected to an additional phase relaxation mechanism that features an increase in the relaxation rate from the center to the periphery of the EPR spectrum. Since the EPR spectrum of GdSL is the sum of subspectra of the individual EPR transitions, we attribute this field dependence to transition dependent phase relaxation. Using simulations of the EPR spectra and its decomposition into the individual transition subspectra, we isolated the phase relaxation of each transition and found that its rate increases with |ms|. We suggest that this mechanism is due to transient zero field splitting (tZFS), where its magnitude and correlation time are scaled down and distributed as compared with similar situations in liquids. This tZFS induced phase relaxation mechanism becomes dominant (or at least significant) when all other well-known phase relaxation mechanisms, such as spectral diffusion caused by nuclear spin diffusion, instantaneous and electron spin spectral diffusion, are significantly suppressed by matrix deuteration and low concentration, and when the temperature is sufficiently low to disable spin lattice interaction as a source of phase relaxation.

The Northwick Park Heart Study: evidence from the laboratory

The Northwick Park Heart Study (NPHS) has shown associations of high plasma fibrinogen and factor VII (FVIIc) levels with the risk of death from coronary heart disease (CHD). The finding for fibrinogen has been confirmed in many other studies. Whereas one further study has found a similar prospective association for FVIIc, several have not. Experimental studies have demonstrated the impact that the coagulation activity of fibrinogen and FVIIc have on the progression and phenotype of atherosclerotic lesions. FVIIc-driven thrombin generation and fibrin formation within the vessel wall are important determinants of both plaque (in)stability and atherothrombosis. In blood, local concentrations of FVIIc and thrombin may be sufficient to allow interactions between these serine proteases and protease-activated receptors, to drive cellular inflammatory reactions that further promote these processes. Local fibrinogen concentrations dictate fibrin clot structure and resistance to fibrinolysis. Within the atherosclerotic plaque, coagulation reactions driven by proinflammatory stimuli may initially support lesion stability (as part of wound healing), but, with advanced inflammation, thrombin and fibrin generation diminish because of proteolytic activity contributing to plaque instability. The NPHS findings have proved controversial, but, in the light of current knowledge, a reappraisal of the importance of FVIIc and fibrinogen in atherosclerosis, atherothrombosis and CHD is justified. Hypercoagulability, reflected in turn by thrombin generation capacity, and local concentrations of coagulation proteins, including FVIIc and fibrinogen, is linked to plaque phenotype, and even minute local concentrations of fibrinogen and proteases such as FVIIc may affect thrombin generation capacity.

Capturing clinician-client interaction: development of the 4D&4R observational tool

AIM

To report on the development of an observation tool that can help a single researcher to collect field data about clinician and client interactions.

BACKGROUND

Qualitative studies from a range of disciplines investigate the dynamics of interactions between clinicians and clients. These studies share and report findings but rarely provide details on the practical challenges and methods involved in managing such interactions when collecting rich ethnographic data.

REVIEW METHODS

Development of the observational tool was informed by the study's requirements and context, previous research, and the authors cross-disciplinary knowledge and experience.

DISCUSSION

In relation to how clinicians interact with clients and how clients respond, four domains have been identified and integrated into the observational tool. These domains act as prompts during observations of interactions between clients and nurses. Use of the tool has indicated its effectiveness in assisting with observations and the recording of field notes.

CONCLUSION

The article shows how to develop a tool for qualitative field-data collection. The method can be adapted to studies that require observations of interactions and its components can be modified to suit their fields of study. IMPLICATIONS FOR PRACTICE OR RESEARCH: The 4D&4R tool discussed in this article provides indicators of clinician-client interactions and is transferable to other research and practice contexts

Navigating motherhood choices in the context of rheumatoid arthritis: women's stories

OBJECTIVE

Planning a family is a complex decision. For women with chronic conditions such as rheumatoid arthritis (RA), there are additional concerns about their own and their baby's health. This qualitative study examined women's experiences of negotiating their family decisions in the context of RA.

METHODS

A qualitative study was conducted in 14 women who provided a written account of their motherhood decisions and experiences. Those 'stories' were then thematically analysed.

RESULTS

RA was found to affect women's motherhood decisions and experiences. Three key themes were identified for both the process of decision making and the experience of that decision: capacity, uncertainty and acceptance. Only two of the women decided not to have children, while for others the decision centred on changing expectations from the number of children they planned to have, to parenting within the restrictions of their physical abilities.

CONCLUSION

While many women struggled through the negotiations of their motherhood choices, those who chose to have children reported great joy in that experience. The challenges faced by women with RA contemplating motherhood, however, highlight the need for understanding and support from health professionals and the provision of resources so that women can make informed choices.

Digging over that old ground: an Australian perspective of women's experience of psychosocial assessment and depression screening in pregnancy and following birth

Background

There is increasing recognition of the need to identify risk factors for poor mental health in pregnancy and following birth. In New South Wales, Australia, health policy mandates psychosocial assessment and depression screening for all women at the antenatal booking visit and at six to eight weeks after birth. Few studies have explored in-depth women’s experience of assessment and how disclosures of sensitive information are managed by midwives and nurses. This paper describes women’s experience of psychosocial assessment and depression screening examining the meaning they attribute to assessment and how this influences their response.

Methods

This qualitative ethnographic study included 34 women who were observed antenatally in the clinic with 18 midwives and 20 of the same women who were observed during their interaction with 13 child and family health nurses after birth in the home or the clinic environment. An observational tool, 4D&4R, together with field notes was used to record observations and were analysed descriptively using frequencies. Women also participated in face to face interviews. Field note and interview data was analysed thematically and similarities and differences across different time points were identified.

Results

Most participants reported that it was acceptable to them to be asked the psychosocial questions however they felt unprepared for the sensitive nature of the questions asked. Women with a history of trauma or loss were distressed by retelling their experiences. Five key themes emerged. Three themes; ’Unexpected: a bit out of the blue’, ‘Intrusive: very personal questions’ and ‘Uncomfortable: digging over that old ground’, describe the impact that assessment had on women. Women also emphasised that the approach taken by the midwife or nurse during assessment influenced their experience and in some cases what they reported. This is reflected in the themes titled: Approach: ’sensitivity and care’ and ’being watched’.

Conclusions

The findings emphasise the need for health services to better prepare women for this assessment prior to and after birth. It is crucial that health professionals are educationally prepared for this work and receive ongoing training and support in order to always deliver care that is empathetic and sensitive to women who are disclosing personal information.

Negotiating policy in practice: child and family health nurses' approach to the process of postnatal psychosocial assessment

Background

There is growing recognition internationally of the need to identify women with risk factors for poor perinatal mental health in pregnancy and following birth. In the state of New South Wales, Australia the Supporting Families Early policy provides a framework of assessment and support for women and families and includes routine psychosocial assessment and depression screening. This study investigated the approach taken by Child and Family Health Nurses (CFHNs) following birth to assessment and screening as recommended by state policy. This was a qualitative ethnographic study that included 83 CFHN and 20 women. Observations occurred with thirteen nurses; with 20 women, in the home or the clinic environment. An additional 70 nurses participated in discussion groups. An observational tool (4D&4R) and field notes were used to record observations and analysed descriptively using frequencies. Field notes, interview data and discussion group transcripts were analysed thematically.

Methods

This was a qualitative ethnographic study that included 83 CFHN and 20 women. Observations occurred with thirteen nurses; with 20 women, in the home or the clinic environment. An additional 70 nurses participated in discussion groups. An observational tool (4D&4R) and field notes were used to record observations and analysed descriptively using frequencies. Field notes, interview data and discussion group transcripts were analysed thematically.

Results

CFHNs demonstrated a range of approaches to assessment and screening. Psychosocial assessment was conducted in 50% (10 out of the 20) of the interactions observed; however, all the women were screened using the Edinburgh Depression Scale. Four major themes that represent the approach taken to the assessment process were identified: ‘Engagement: getting that first bit right’, ‘Doing some paperwork’, ‘Creating comfort’ and ‘Psychosocial assessment: doing it another way’. Nurses utilised other skills such as observing the women interacting with their baby, taking note of non verbal communication and using intuition to develop a clinical decision.

Conclusion

Overall, nurses’ took a sensitive and caring approach to assessment and screening, however, there were differences in interpretations of the policy recommendations across the two sites. Nurses adopt a flexible, relationship-based approach to the assessment process; however, they experience tension when required to incorporate structured psychosocial assessment processes. To undertake assessment and screening effectively, CFHNs require ongoing support, training and supervision to maintain this sensitive and emotionally challenging work.

Measuring engagement in deliberate self-harm behaviours: psychometric evaluation of six scales

BACKGROUND

Engagement in Deliberate Self-Harm (DSH) is commonly measured by behavioural scales comprised of specific methods of self-harm. However, there is a scarcity of information about the degree to which the methods relate to the same DSH construct although such scales are routinely used to provide a DSH total score. This study addresses the shortfall by evaluating the dimensionality of six commonly used behavioural measures of DSH.

METHODS

The DSH measures were Self-Injury Questionnaire Treatment Related (SIQTR), Self-Injurious Thoughts and Behaviors Interview (SITBI), Deliberate Self-Harm Inventory (DSHI), Inventory of Statements About Self-Injury (ISAS), Self-Harm Information Form (SHIF) and Self-Harm Inventory (SHI). The behavioural scales contained in each measure were administered to 568 young Australians aged 18 to 30 years (62% university students, 21% mental health patients, and 17% community members). Scale quality was examined against the stringent standards for unidimensional measurement provided by the Rasch model.

RESULTS

According to the stringent post-hoc tests provided by the Rasch measurement model, there is support for the unidimensionality of the items contained within each of the scales. All six scales contained items with differential item functioning, four scales contained items with local response dependency, and one item was grossly misfitting (due to a lack of discrimination).

CONCLUSIONS

This study supports the use of behavioural scales to measure a DSH construct, justifies the summing of items to form a total DSH score, informs the hierarchy of DSH methods in each scale, and extends the previous evidence for reliability and external validity (as provided by test developers) to a more complete account of scale quality. Given the overall adequacy of all six scales, clinicians and researchers are recommended to select the scale that best matches their adopted definition of DSH.

A preliminary investigation of cognitive function in rheumatoid arthritis patients on long-term methotrexate treatment

Some studies suggest that cognitive function is impaired in rheumatoid arthritis patients. One possible influence may be commonly used rheumatoid arthritis treatment, methotrexate. This study examined cognitive function in long-term methotrexate users with rheumatoid arthritis and, using a 24-hour pre- and post-methotrexate dose administration, investigated whether there may be transient cognitive function changes. Rheumatoid arthritis patients ( n = 35) were assessed immediately before taking methotrexate and 24 hours later. Low and high methotrexate dose groups were then compared. Cognitive performance was unchanged across two assessment points and was within the normal range, although lower in high methotrexate dose group.