Camden and Islington NHS Foundation Trust
Recent publications
Background: Transcranial direct current stimulation (tDCS) is a non-invasive form of neurostimulation with potential for development as a self-administered intervention. It has shown promise as a safe and effective treatment for obsessive compulsive disorder (OCD) in a small number of studies. The two most favourable stimulation targets appear to be the left orbitofrontal cortex (L-OFC) and the supplementary motor area (SMA). We report the first study to test these targets head-to-head within a randomised sham-controlled trial. Our aim was to inform the design of future clinical research studies, by focussing on the acceptability and safety of the intervention, feasibility of recruitment, adherence to and tolerability of tDCS, and the size of any treatment-effect. Methods: FEATSOCS was a randomised, double-blind, sham-controlled, cross-over, multicentre study. Twenty adults with DSM-5-defined OCD were randomised to treatment, comprising three courses of clinic-based tDCS (SMA, L-OFC, Sham), randomly allocated and delivered in counterbalanced order. Each course comprised four 20-min 2 mA stimulations, delivered over two consecutive days, separated by a 'washout' period of at least four weeks. Assessments were carried out by raters who were blind to stimulation-type. Clinical outcomes were assessed before, during, and up to four weeks after stimulation. Patient representatives with lived experience of OCD were actively involved at all stages. Results: Clinicians showed willingness to recruit participants and recruitment to target was achieved. Adherence to treatment and study interventions was generally good, with only two dropouts. There were no serious adverse events, and adverse effects which did occur were transient and mostly mild in intensity. Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) scores were numerically improved from baseline to 24 h after the final stimulation across all intervention groups but tended to worsen thereafter. The greatest effect size was seen in the L-OFC arm, (Cohen's d = -0.5 [95% CI -1.2 to 0.2] versus Sham), suggesting this stimulation site should be pursued in further studies. Additional significant sham referenced improvements in secondary outcomes occurred in the L-OFC arm, and to a lesser extent with SMA stimulation. Conclusions: tDCS was acceptable, practicable to apply, well-tolerated and appears a promising potential treatment for OCD. The L-OFC represents the most promising target based on clinical changes, though the effects on OCD symptoms were not statistically significant compared to sham. SMA stimulation showed lesser signs of promise. Further investigation of tDCS in OCD is warranted, to determine the optimal stimulation protocol (current, frequency, duration), longer-term effectiveness and brain-based mechanisms of effect. If efficacy is substantiated, consideration of home-based approaches represents a rational next step. Trial registration: ISRCTN17937049. https://doi.org/10.1186/ISRCTN17937049.
Background The COVID-19 pandemic resulted in a rapid shift from traditional face-to-face care provision towards delivering mental health care remotely through telecommunications, often referred to as telemental health care. However, the manner and extent of telemental health implementation have varied considerably across settings and areas, and substantial barriers are encountered. There is, therefore, a need to identify what works best for service users and staff and establish the key mechanisms for efficient integration into routine care. Objective We aimed to identify investigations of pre-planned strategies reported in the literature intended to achieve or improve effective and sustained implementation of telemental health approaches (including video calls, telephone calls, text messaging platforms or a combination of any of these approaches with face-to-face care), and to evaluate how different strategies influence implementation outcomes. Methods A systematic review was conducted, with five databases searched for any relevant literature published between January 2010 and July 2021. Studies were eligible if they took place in specialist mental health services and focused on pre-planned strategies to achieve or improve the delivery of mental health care through remote communication between mental health professionals or between mental health professionals and service users, family members, unpaid carers, or peer supporters. All included studies were quality-assessed. Data were synthesised using the Expert Recommendations for Implementing Change (ERIC) compilation of implementation strategies and the taxonomy of implementation outcomes. Results A total of 14 studies were identified as meeting the inclusion criteria from a total of 14,294 records of which 338 were assessed at full text. All ERIC implementation strategies were used by at least one study, the most commonly reported being ‘Train and educate stakeholders’. All studies reported using a combination of several implementation strategies, with the mean number of strategies used per study of 3.5 (range 2–6), many of which were reported to result in an improvement in implementation over time. Few studies specifically investigated a single implementation strategy and its associated outcomes, making conclusions regarding the most beneficial strategy difficult to draw. Conclusions Using a combination of implementation strategies appears to be a helpful method of supporting the implementation of telemental health. Further research is needed to test the impact of specific implementation strategies on implementation outcomes.
Introduction: The mental health of elite athletes has been recognised as of great importance. There have been relatively few studies examining the prevalence of mental health problems in swimmers. None have commented on the range of psychosocial problems associated with mental ill-health. The aim of this study was to identify the prevalence of common mental health problems and psychosocial problems in elite swimmers. Methods: The study was conducted on a national swimming squad competing at the international level. All athletes (n=55) were invited to participate. The response rate was 63.3% (n=36). The study was cross-sectional in design. Data was collected using a battery of psychometric tests yielding information on distress (The Distress Screener), anxiety and depression (PHQ-9, K10), sleep disturbance (PROMIS scale), alcohol consumption (AUDIT-C), smoking behaviour, adverse nutrition behaviour, career satisfaction (Career Satisfaction Scale) and mental toughness (Mental Toughness Index). Results: The prevalence of depression was 14% (n=5). Six percent (n=2) reported suicidal ideation in the last 2 weeks. Fourteen percent met criteria for distress. There were positive correlations between depression and sleep disturbance ( r=.343, p<.05), between anxiety/depression and distress ( r=.380, p<.05), and between depression and distress ( r=.531, p<.01). Career dissatisfaction was identified in 46% of participants and was inversely correlated with mental toughness ( r=.485, p<.01). Low mental toughness and adverse alcohol use were identified in 37% and 23% of participants, respectively. Conclusions: Elite swimmers experience common mental illnesses and associated psychosocial problems. There is a relationship between career dissatisfaction and low mental toughness. Sport governing bodies should assess their own athlete populations and implement programmes to support mental health.
Despite evidence suggesting that insomnia is associated with the risk of dementia and cognitive dysfunction, studies have shown mixed results. Dementia has a long prodromal phase, and studies with long follow‐up are required to avoid reverse causality. In our 11‐year follow‐up study, we assessed whether probable insomnia disorder (PID) based on diagnostic criteria, and insomnia symptoms were associated with risk of all‐cause dementia, Alzheimer's disease (AD) and cognition, measured with the Montreal Cognitive Assessment scale. We also examined if Apolipoprotein E genotype modified any associations with dementia through interaction. We analysed data from 7492 participants in the Norwegian Trøndelag Health Study. PID was not associated with all‐cause dementia (odds ratio = 1.03, 95% confidence interval = 0.74–1.43), AD (odds ratio = 1.07, 95% confidence interval = 0.71–1.60) or Montreal Cognitive Assessment score (regression coefficient = 0.37, 95% confidence interval = −0.06 to 0.80). The insomnia symptom “difficulties maintaining sleep” was associated with a lower risk of all‐cause dementia (odds ratio = 0.81, 95% confidence interval = 0.67–0.98), AD (odds ratio = 0.73, 95% confidence interval = 0.57–0.93), and better Montreal Cognitive Assessment score, mean 0.40 units (95% confidence interval = 0.15–0.64). No interaction with Apolipoprotein E genotype was found. PID and insomnia symptoms did not increase the risk of dementia in our study. More research with longer follow‐up is needed, and future studies should explore if the associations to dementia risk vary across insomnia subtypes.
Background: Quality of care and access to effective interventions have been widely criticised as limited for people diagnosed with 'personality disorder' or who have comparable needs (described in some recent papers as "Complex Emotional Needs" (CEN). It is important to identify effective interventions and the optimal context and mode of delivery for people with CEN. We aimed to investigate the effectiveness of psychosocial interventions delivered in community and outpatient settings in treating symptoms associated with 'personality disorder', and the moderating effects of treatment-related variables. Methods: We systematically searched MEDLINE, EMBASE, PsycINFO, CINAHL, HMIC, ASSIA for articles published in English, from inception to November 23, 2020. We included randomized controlled trials examining interventions provided in community or outpatient settings for CEN. The primary outcome was 'personality disorder' symptoms, while secondary outcomes included anxiety symptoms, depressive symptoms, and global psychiatric symptoms. Random-effects meta-analysis was conducted for each outcome, and meta-regression analysis was performed to assess the moderating effects of treatment characteristics. The quality of the studies and the degree of publication bias was assessed. Results: We included 54 trials (n = 3716 participants) in the meta-analysis. We found a large effect size (g = 0.78, 95% CI: 0.56 to 1.01, p < 0.0001) favoring interventions for 'borderline personality disorder' (BPD) symptoms over Treatment as Usual or Waitlist (TAU/WL), and the efficacy was maintained at follow-up (g = 1.01, 95% CI: 0.37 to 1.65, p = 0.002). Interventions effectively reduced anxiety symptoms (g = 0.58, 95% CI: 0.21 to 0.95, p = 0.002), depressive symptoms (g = 0.57, 95% CI: 0.32 to 0.83, p < 0.0001), and global psychiatric symptoms (g = 0.50, 95% CI: 0.35 to 0.66, p < 0.0001) compared to TAU/WL. The intervention types were equally effective in treating all symptom categories assessed. Treatment duration and treatment intensity did not moderate the effectiveness of the interventions for any outcome. Conclusions: People with a 'personality disorder' diagnosis benefited from psychological and psychosocial interventions delivered in community or outpatient settings, with all therapeutic approaches showing similar effectiveness. Mental health services should provide people with CEN with specialised treatments in accordance with the availability and the patients' preferences.
Background: Research has previously distinguished between complex post-traumatic stress disorder (CPTSD) and PTSD, with the former including a range of disturbances in self-regulatory capacities in addition to difficulties associated with PTSD. Clinical guidelines have previously recommended a phase-based approach for the treatment of CPTSD, yet the final ‘reintegration’ phase of treatment has been overlooked in research, with limited evidence into its value and effectiveness, and inconsistencies in its definitions and understanding. Objective: We set out to define and determine the key principles of ‘reintegration’ and to specify the components and method of delivery of treatment. Method: Leading national and international clinical and academic experts in CPTSD were interviewed and asked about their views of how ‘reintegration’ should be defined, its role in the treatment of CPTSD, what it should be composed of, the key principles of its delivery, and how it should be evaluated. We analysed transcripts of the interviews following the principles of Codebook Thematic Analysis. Results: We conducted 16 interviews with leading national and international experts with at least 10 years’ experience of treating people with CPTSD. Themes derived from our analysis demonstrated that while the definition and composition of reintegration varied greatly between experts, the key principles in its delivery were consistent across all experts. Conclusions: The results of this study lay the foundation for a framework of what reintegration is and how it can be used in, but also highlight the need for more research to be conducted on the role of reintegration in the treatment of CPTSD. Consensus for the definition and composition of reintegration is still yet to be reached. Possible measures for evaluating reintegration should also be explored in the future.
Many family carers of a person with dementia experience pre‐death grief. We aimed to identify strategies that help carers manage pre‐death grief. We hypothesised that emotion and problem focused styles would be associated with lower, and dysfunctional coping with higher grief intensity. Mixed methods observational study using structured and semi‐structured interviews with 150 family carers of people with dementia living at home or in a care home. Most participants were female (77%), caring for a parent (48%) or partner/spouse (47%) with mild (25%), moderate (43%) or severe (32%) dementia. They completed the Marwit‐Meuser Caregiver Grief Inventory Short Form and the Brief Coping Orientation to Problems Experienced questionnaire. We asked carers to identify strategies used for managing grief. We recorded field notes for 150 interviews and audio‐recorded additional interviews with a sub‐sample of 16 participants. Correlations indicated that emotion‐oriented coping was associated with lower grief (R=‐0.341), and dysfunctional coping with higher grief (R=0. 435), with a small association with problem‐focused strategies (R= ‐0.109), partly supporting our hypothesis. Our qualitative themes broadly match the three Brief‐COPE styles. Unhelpful strategies of denial and avoidance align with dysfunctional coping strategies. Psychological strategies (including acceptance and humour) and seeking support were consistent with emotion‐focused strategies, but we did not identify a theme relating to problem‐focused strategies. Most carers identified multiple strategies for processing grief. Carers could readily identify supports and services that they found helpful for managing pre‐death grief, yet current services appear under‐resourced to meet growing demand. (ClinicalTrials.gov ID: NCT03332979). This article is protected by copyright. All rights reserved. Pre‐death grief is common amongst carers of people living with dementia, however, little is known about how they manage and process their grief. Most carers in our study were experiencing grief and used multiple strategies for managing their grief. Our findings provide support that in the context of a progressive, chronic condition, carers can find the carer experience rewarding and lead to personal growth, but some will struggle and find their situation futile. Carers could readily identify supports and services they found helpful, suggesting that holistic, individualised assessment of the carer’s practical and emotional needs could identify key supports that would enable them to feel supported and have the time to consider and process difficult emotions. Current bereavement models may underestimate the level of formal counselling and support these carers need. While family and social networks were important, many did not want to burden family and friends and felt that their network could not fully understand their experiences. Formal supports offered an independent avenue for support that was not bound within existing complex relationships. However, current services appear to be under‐resourced to meet growing demand. Pre‐death grief is common amongst carers of people living with dementia, however, little is known about how they manage and process their grief. Most carers in our study were experiencing grief and used multiple strategies for managing their grief. Our findings provide support that in the context of a progressive, chronic condition, carers can find the carer experience rewarding and lead to personal growth, but some will struggle and find their situation futile. Carers could readily identify supports and services they found helpful, suggesting that holistic, individualised assessment of the carer’s practical and emotional needs could identify key supports that would enable them to feel supported and have the time to consider and process difficult emotions. Current bereavement models may underestimate the level of formal counselling and support these carers need. While family and social networks were important, many did not want to burden family and friends and felt that their network could not fully understand their experiences. Formal supports offered an independent avenue for support that was not bound within existing complex relationships. However, current services appear to be under‐resourced to meet growing demand.
Objectives: We culturally adapted STrAtegies for RelaTives (START), a clinically and cost-effective intervention for dementia family carers, for Black and South Asian families. It had previously been delivered to family carers around the time of diagnosis, when most people with dementia had very mild, mild or moderate dementia. Methods: We interviewed a maximum variation sample of family carers (phase one; n = 15 South Asian; n = 11 Black) about what aspect of START, required cultural adaptation, then analysed it thematically using the Cultural Treatment Adaptation Framework then adapted it in English and into Urdu. Facilitators then delivered START individually to carers (phase two; n = 13 South Asian; n = 8 Black). We assessed acceptability and feasibility through the number of sessions attended, score for fidelity to the intervention and interviewing family carers about their experiences. We used the Hospital Anxiety and Depression Scale. to examine whether immediate changes in family carers' mental health were in line with previous studies. Results: In phase one we made adaptations to peripheral elements of START, clarifying language, increasing illustrative vignettes numbers, emphasising privacy and the facilitator's cultural competence and making images ethnically diverse. In phase two 21 family carers consented to receive the adapted intervention; 12 completed ≥5/8 sessions; four completed fewer sessions and five never started. Baseline HADS score (n = 21) was 14.4 (SD = 9.8) but for those who we were able to follow up was 12.3 (SD 8.1) and immediately post-intervention was 11.3 (n = 10; SD = 6.1). Family carers were positive about the adapted START and continued to use elements after the intervention. Conclusions: Culturally adapted START was acceptable and feasible in South Asian and Black UK-based family carers and changes in mental health were in line with those in the original clinical trial. Our study shows that culturally inclusive START was also acceptable. Changes made in adaptations were relevant to all populations. We now use the adapted version for all family carers irrespective of ethnicity.
Introduction Open dialog (OD) is a both a therapeutic practice and a service delivery model that offers an integrated response to mental health care through mobilizing resources within the service user’s family and community networks through joint network meetings. Therapist adherence is a crucial to the effective delivery of interventions. A key way to measure this is through structured observation tools. Aims The aim of this research project is to develop and refine the Dialogic Practice Adherence Scale, for use in OD research trials in the United Kingdom. Methods This study was a mixed methods approach to the development of an OD practitioner adherence measure. Initial steps involved meetings and discussions with experts and a review of the literature. Content validation studies were completed using a modified Delphi technique. To assess reliability of the measure, OD network meetings were audio-recorded, and tapes were rated by two independent researchers. Inter-rater reliability and internal consistency were assessed through quantitative approaches assessing variance. Results Results provide a description of how the OD Adherence Manual was developed in collaboration. Validation surveys showed high levels on consensus among experts in the field on the key elements of OD network meetings. Inter-rater reliability for the total score was excellent and internal consistency analyses suggest the scale is highly reliable. Discussion The scale presented here is an initial attempt at rating practitioner adherence in OD network meetings. It provides encouraging evidence that this can be done with strong validity and reliability and can be completed by a range of raters with varying levels of clinical experience.
Based on research from previous pandemics, studies of critical care survivors, and emerging COVID-19 data, we estimate that up to 30% of survivors of severe COVID will develop PTSD. PTSD is frequently undetected across primary and secondary care settings and the psychological needs of survivors may be overshadowed by a focus on physical recovery. Delayed PTSD diagnosis is associated with poor outcomes. There is a clear case for survivors of severe COVID to be systematically screened for PTSD, and those that develop PTSD should receive timely access to evidence-based treatment for PTSD and other mental health problems by multidisciplinary teams.
Background Cardiovascular disease among patients with severe mental illness in England is a major preventable contributor to premature mortality. To address this, a nurse and peer-coach delivered service (Primrose-A) was implemented in three London general practices from 2019 (implementation continued during COVID-19). This study aimed to conduct interviews with patient and staff to determine the acceptability of, and experiences with, Primrose-A. Methods Eight patients who had received Primrose-A, and 3 nurses, 1 GP, and 1 peer-coach who had delivered Primrose-A in three London-based GP surgeries. Semi-structured audio-recorded interviews were conducted. Reflexive thematic analysis was used to identify themes from the transcribed interviews. Findings Overall, Primrose-A was viewed positively by patients and staff, with participants describing success in improving patients’ mental health, isolation, motivation, and physical health. Therapeutic relationships between staff and patients, and long regular appointments were important facilitators of patient engagement and acceptance of the intervention. Several barriers to the implementation of Primrose-A were identified, including training, administrative and communication issues, burden of time and resources, and COVID-19. Conclusions Intervention acceptability could be enhanced by providing longer-term continuity of care paired with more peer-coaching sessions to build positive relationships and facilitate sustained health behaviour change. Future implementation of Primrose-A or similar interventions should consider: 1) training sufficiency (covering physical and mental health, including addiction), 2) adequate staffing to deliver the intervention, 3) facilitation of clear communication pathways between staff, and 4) supporting administrative processes.
Background: There is substantial variation in patient symptoms following psychological therapy for depression and anxiety. However, reliance on endpoint outcomes ignores additional interindividual variation during therapy. Knowing a patient's likely symptom trajectories could guide clinical decisions. We aimed to identify latent classes of patients with similar symptom trajectories over the course of psychological therapy and explore associations between baseline variables and trajectory class. Methods: Patients received high-intensity psychological treatment for common mental health problems at National Health Service Improving Access to Psychological Therapies services in South London (N = 16 258). To identify trajectories, we performed growth mixture modelling of depression and anxiety symptoms over 11 sessions. We then ran multinomial regressions to identify baseline variables associated with trajectory class membership. Results: Trajectories of depression and anxiety symptoms were highly similar and best modelled by four classes. Three classes started with moderate-severe symptoms and showed (1) no change, (2) gradual improvement, and (3) fast improvement. A final class (4) showed initially mild symptoms and minimal improvement. Within the moderate-severe baseline symptom classes, patients in the two showing improvement as opposed to no change tended not to be prescribed psychotropic medication or report a disability and were in employment. Patients showing fast improvement additionally reported lower baseline functional impairment on average. Conclusions: Multiple trajectory classes of depression and anxiety symptoms were associated with baseline characteristics. Identifying the most likely trajectory for a patient at the start of treatment could inform decisions about the suitability and continuation of therapy, ultimately improving patient outcomes.
Background One of the many challenges faced by mental health services during the COVID-19 pandemic was how to deliver care during lockdown. In community and crisis services, this often meant rapidly adopting or expanding the use of telemental health technologies, including phone and video calls. The aim of this study is to explore variations in use and report staff views of such technologies during the early stages of the pandemic. The primary analysis compared rates of use between professions, demographic groups, genders, regions, and crisis and community services. Methods We used data from an online survey conducted by the Mental Health Policy Research Unit in Spring 2020 regarding the impact of the pandemic on mental healthcare in the United Kingdom. We included quantitative data from all professional groups working in community or crisis services providing care to working age adults, including general and specialist services. Our outcome of interest was the percentage of clients whom clinicians primarily interacted with via videocall. We also collected demographics and professional characteristics such as the type of mental health service respondents worked in. In addition, we explored respondents’ views and experiences of telemental health as a medium for providing care. Results 978 participants were included in the primary analysis (834 provided outcome data for community services, 193 for crisis services). In community services, virtually all staff reported stopping some or all face-to-face appointments following the onset of the pandemic, with a large majority using video or phone call appointments where possible instead. Telemental health use was higher in community than in crisis services, and amongst professionals who mainly provided psychotherapy or peer support than in other groups. There was also evidence of use being lower in regions in Northern England, Scotland, and Wales than elsewhere. There was no evidence of an association with staff gender, age, or ethnicity. Staff were generally positive about telemental health and intended to make more use of technologies following the pandemic. However, significant barriers to its use were also reported, often involving skills and available infrastructure. Conclusions Despite its rapid implementation, telemental health was viewed positively by clinicians who saw it as an effective alternative to face-to-face appointments in some contexts, including during the pandemic. However, adoption of the technology also has the potential to exacerbate existing or create new inequalities without effective management of training and infrastructure needs.
Loneliness is a significant problem for young people and is associated with a range of physical and mental health difficulties. Meta-analyses have identified that interventions aimed at young people who report loneliness as their primary problem are lacking within the literature. In adults, the most effective interventions for loneliness are those which target the underlying maladaptive social cognitions. Therefore, we have developed a modular Cognitive Behavioural Therapy (CBT) intervention for children and young people. The aim of this study is to conduct a multiple baseline single-case experimental design (SCED) to assess the efficacy, feasibility and acceptability of this intervention. In total 6–8 11–18-year-olds and their families will be recruited. The design consists of AB+ post-intervention, where A is the baseline phase, B is the intervention phase and then a post-intervention phase. Participants will complete a baseline assessment, before being randomised to one of four different baseline lengths (12 days, 19 days, 26 days or 33 days). Participants will then complete an average of 12 sessions of CBT, with the aim being to reduce their feelings of loneliness. Participants will then complete a 12-day post-intervention phase. Participant loneliness will be repeatedly assessed throughout the three phases of the intervention using the Three-item Loneliness Scale, which will be the primary outcome. Secondary outcomes will be reliable and clinically meaningful change on the UCLA Loneliness Scale, Revised Child Anxiety and Depression Scale (RCADS) and Strengths and Difficulties Questionnaire (SDQ). Feasibility and participant satisfaction will also be assessed and reported. Trial registration: ClinicalTrails.gov trial registration number: NCT05149963 (Date registered: 07.12.2021). https://www.clinicaltrials.gov/ct2/show/NCT05149963?term=cbt&cond=loneliness&draw=2&rank=1 .
Background Many people with Common Mental Disorders (CMDs), especially men, people from older age groups, and ethnic minority backgrounds, receive no treatment. Self-acknowledgement of mental illness symptoms, and a professional diagnosis are usually required to access treatment. To understand barriers, we therefore tested whether these groups were relatively less likely to self-diagnose a CMD, or to receive a professional diagnosis. Methods We analysed data from the 2014 English Adult Psychiatric Morbidity Survey (APMS). We used regression models to examine whether gender, age, and minority ethnic status were associated with professional and self-diagnosis, after controlling for CMD symptoms. Results 27.3 % of the population reported a professional and self-diagnosis of CMD, 15.9 % a self- diagnosis only, and the remainder no diagnosis. Odds of professional diagnosis were lower for men compared with women (adjusted odds ratio [AOR] 0.54, 95 % confidence intervals [CI] 0.47–0.62). People from White Other (0.49, 0.36–0.67), Black (0.31, 0.18–0.51), and Asian (0.22, 0.15–0.33) groups were less likely than the White British group to receive a professional diagnosis. The least likely age group to have a professional CMD diagnosis (relative to adults aged 16–34) were people aged over 75 (0.52, 0.39–0.69). Patterns were similar for self-diagnosis. Limitations Ethnicity categories were heterogeneous. Data are cross-sectional, and selection and response bias are possible. Conclusions For every three people who self-diagnose CMD, two have a professional diagnosis. Men, ethnic minority, and older age groups are less likely to receive a diagnosis or self-diagnose after adjustment for presence of symptoms.
Background Psychiatrists are at high risk of developing burnout and mental health problems mainly due to their emotionally demanding jobs, difficult working conditions, long working hours, and poor work-life balance. As leisure activities are associated with better physical and mental health, engaging in these activities has been recommended as a measure to improve the wellbeing of healthcare workers. However, it is unclear the extent of which psychiatrists and trainees are involved in leisure activities, what type of activities they prefer, or how these impact their self-perceived health, stress, confidence in stress management, and satisfaction with their social support.Objective The aim of this study was to identify differences in self-perceived health, perceived stress, confidence in stress management, and satisfaction with social support, between psychiatrists and trainees who engage in different leisure activities, compared with those who do not.Methods This was a cross-sectional study, including Mexican psychiatrists (n = 355) and trainees (n = 330) who agreed to participate through an online survey.Results73.1% of participants engaged in some leisure activity, being solitary-passive activities the most reported. Those who have a leisure activity reported lower stress, greater confidence in stress management, and more satisfaction with their social support. Passive-solitary activities were associated with less perceived stress and better confidence in stress management, while active-solitary and social activities were associated with better satisfaction with social support.Conclusion Psychiatrists' and trainees' wellbeing benefits from engagement in leisure activities, which should be part of their daily schedules to reduce stress, and potentially improve their mental health.
Background When experiencing mental distress, many university students seek support from their peers. In schools and mental health services, formalised peer support interventions have demonstrated some success but implementation challenges have been reported. This study aimed to assess the feasibility, acceptability and safety of a novel manualized peer support intervention and associated data collection processes. Methods A longitudinal mixed methods study was conducted following the pilot of a peer support intervention at a large London university between June 2021 and May 2022. The study utilised data routinely recorded on all students who booked a peer support session, focus groups with nine peer workers and five staff members implementing the intervention, pre-post intervention surveys with 13 students and qualitative interviews with 10 of those students. Results 169 bookings were made during the pilot, of which 130 (77%) were attended, with November the peak month. Staff and peer workers described strong motivation and commitment to implement the intervention, noting that the peer support model and peer worker role addressed previously unmet needs at the university. However, students described implementation problems relating to the coherence of the intervention and the burden of participation. While students mostly described acceptable experiences, there were examples where acceptability was lower. No adverse events were reported during the pilot. Conclusion The training and supervision of peer workers, and the provision of one-to-one peer support to students was found to be feasible, mostly acceptable, and safe. However, sustained implementation difficulties were observed. These pose challenges to the scalability of peer support in universities. We make recommendations to improve implementation of peer support including improving reach, greater clarity about the intervention, and fuller involvement of students throughout.
Background Meta-analyses support an association between anxiety in older adulthood and dementia. The aim of this study was to use routinely collected health data to test whether treatment of anxiety disorders through psychological intervention is associated with a lower incidence of dementia. Methods In this prospective cohort study, data from nationally provided psychological therapy services in England termed Improving Access to Psychological Therapies from 2012 to 2019 were linked to medical records, including dementia diagnoses as defined by the tenth edition of the International Classification of Diseases, up to 8 follow-up years later. Inclusion criteria were as follows: (1) patients who were aged 65 years and older; (2) patients with a probable anxiety disorder; and (3) those with no previous or current diagnosis of dementia. Cox proportional hazards models were constructed to test whether reliable improvement in anxiety following psychological intervention was associated with future dementia incidence. The primary outcome was all-cause dementia and cases were identified using ICD-10 dementia codes from Hospital Episode Statistics, Mental Health Services Dataset, and mortality data. For main analyses, hazards ratios (HRs) are presented. Findings Data from 128 077 people aged 65 years and older attending a nationally provided psychological intervention service in England were linked to medical records. 88 019 (69·0%) of 127 064 participants with available gender data were women and 39 585 (31·0%) were men. 111 225 (95·9%) of 115 989 with available ethnicity data were of White ethnicity. The mean age of the sample was 71·55 years (SD 5·69). Fully adjusted models included data from 111 958 people after 16 119 were excluded due to missing data on key variables or covariates. 4510 (4·0%) of 111 958 participants had a dementia diagnosis. The remaining 107 448 (96·0%) were censored either at date of death or when the final follow-up period available for analyses was reached. People who showed reliable improvement in anxiety had lower rates of later dementia diagnosis (3·9%) than those who did not show reliable improvement (5·1%). Reliable improvement in anxiety following psychological intervention was associated with reduced incidence of all-cause dementia (HR 0·83 [95% CI 0·78–0·88]), Alzheimer's disease (HR 0·85 [0·77–0·94]), and vascular dementia (HR 0·80 [0·71–0·90]). Effects did not differ depending on anxiety disorder diagnosis. Interpretation Results showed that reliable improvement in anxiety from psychological therapy was associated with reduced incidence of future dementia. There are multiple plausible explanations for this finding and further research is needed to distinguish between these possibilities. Missing data in the sample limit reliability of findings. Funding Alzheimer's Society, Medical Research Council, Wellcome Trust, and UCLH National Institute for Health and Care Research Biomedical Research Centre.
Objectives: Cost-effectiveness analysis of two 12-week contingency management (CM) schedules targeting heroin-abstinence or attendance at weekly keyworker appointments for opioid agonist treatment (OAT), compared to treatment as usual (TAU). Methods: Cost-effectiveness analysis was conducted alongside a cluster randomised trial of 552 patients from 34 clusters (drug treatment clinics) randomly allocated 1:1:1 to OAT plus weekly keyworker appointments with either: i) CM targeted at heroin-abstinence (CM Abstinence); ii) CM targeted at on-time attendance at weekly appointments (CM Attendance); or, iii) no CM (TAU). The primary cost-effectiveness analysis at 24 weeks post-randomisation took a societal cost perspective with effects measured in heroin-negative urine samples. Results: At 24-weeks, mean differences in weekly heroin-negative urine results compared with TAU were 0.252 (95%CI -0.397 to 0.901) for CM Abstinence and 0.089 (95%CI -0.223 to 0.402) for CM Attendance. Mean differences in costs were £2562 (95%CI £32 to £5092) for CM Abstinence and £317 (95%CI -£882 to £1518) for CM Attendance. Incremental cost-effectiveness ratios were £10,167 per additional heroin-free urine for CM Abstinence and £3,562 for CM Attendance with low probabilities of cost-effectiveness of 3.5% and 36%, respectively. Results were sensitive to timing of follow-up for CM Attendance, which dominated TAU (better outcomes, lower costs) at 12-weeks, with an 88.4% probability of being cost-effective. Probability of cost-effectiveness remained low for CM Abstinence (8.6%). Conclusions: Financial incentives targeted toward heroin-abstinence and treatment-attendance were not cost-effective over the 24-week follow-up. However, CM Attendance was cost-effective over the treatment period (12-weeks), when participants were receiving keyworker appointments and incentives.
Objective We retrospectively evaluated the effectiveness of trauma-focused psychotherapy (TF-P) versus stabilization and waiting in a civilian cohort of patients with an 11th version of the international classification of disease (ICD-11) diagnosis of complex post-traumatic stress disorder (CPTSD). Methods We identified patients with CPTSD treated at a specialist trauma service over a 3-year period by triangulating evidence from self-report questionnaires, file review, and expert-clinician opinion. Patients completed a phase-based treatment: stabilization consisting of symptom management and establishing safety, followed by waiting for treatment (phase 1); individual TF-P in the form of trauma-focused cognitive behavioral therapy (TF-CBT), or eye movement desensitization and reprocessing (EMDR) or TF-CBT plus EMDR (phase 2). Our primary outcome was PTSD symptoms during phase 2 versus phase 1. Secondary outcomes included depressive symptoms, functional impairment, and a proxy CPTSD measure. Exploratory analysis compared outcomes between treatments. Adverse outcomes were recorded. Results Fifty-nine patients were included. Compared to receiving only phase 1, patients completing TF-P showed statistically significant reductions in PTSD [ t (58) = −3.99, p < 0.001], depressive symptoms [ t (58) = −4.41, p < 0.001], functional impairment [ t (58) = −2.26, p = 0.028], and proxy scores for CPTSD [ t (58) = 4.69, p < 0.001]. There were no significant differences in outcomes between different treatments offered during phase 2. Baseline depressive symptoms were associated with higher PTSD symptoms and functional impairment. Conclusions This study suggests that TF-P effectively improves symptoms of CPTSD. However, prospective research with validated measurements is necessary to evaluate current and new treatments and identify personal markers of treatment effectiveness for CPTSD.
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172 members
John Dunn
  • Department of Psychiatry
Antonio Metastasio
  • Department of Psychiatry
Frank Ryan
  • Department of Clinical Psychology
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