The Use of Evaluation Panels During the Development of a Digital Intervention for Veterans Based on Cognitive Behavioral Therapy for Insomnia: Qualitative Evaluation Study

BACKGROUND

Individuals enrolling in the Veterans Health Administration frequently report symptoms consistent with insomnia disorder. Cognitive behavioral therapy for insomnia (CBT-I) is a gold standard treatment for insomnia disorder. While the Veterans Health Administration has successfully implemented a large dissemination effort to train providers in CBT-I, the limited number of trained CBT-I providers continues to restrict the number of individuals who can receive CBT-I. Digital mental health intervention adaptations of CBT-I have been found to have similar efficacy as traditional CBT-I. To help address the unmet need for insomnia disorder treatment, the VA commissioned the creation of a freely available, internet-delivered digital mental health intervention adaptation of CBT-I known as Path to Better Sleep (PTBS).

OBJECTIVE

We aimed to describe the use of evaluation panels composed of veterans and spouses of veterans during the development of PTBS. Specifically, we report on the methods used to conduct the panels, the feedback they provided on elements of the course relevant to user engagement, and how their feedback influenced the design and content of PTBS.

METHODS

A communications firm was contracted to recruit 3 veteran (n=27) and 2 spouse of veteran (n=18) panels and convene them for three 1-hour meetings. Members of the VA team identified key questions for the panels, and the communications firm prepared facilitator guides to elicit feedback on these key questions. The guides provided a script for facilitators to follow while convening the panels. The panels were telephonically conducted, with visual content displayed via remote presentation software. The communications firm prepared reports summarizing the panelists' feedback during each panel meeting. The qualitative feedback described in these reports served as the raw material for this study.

RESULTS

The panel members provided markedly consistent feedback on several elements of PTBS, including recommendations to emphasize the efficacy of CBT-I techniques; clarify and simplify written content as much as possible; and ensure that content is consistent with the lived experiences of veterans. Their feedback was congruent with previous studies on the factors influencing user engagement with digital mental health interventions. Panelist feedback influenced multiple course design decisions, including reducing the effort required to use the course's sleep diary function, making written content more concise, and selecting veteran testimonial videos that emphasized the benefits of treating chronic insomnia symptoms.

CONCLUSIONS

The veteran and spouse evaluation panels provided useful feedback during the design of PTBS. This feedback was used to make concrete revisions and design decisions consistent with existing research on improving user engagement with digital mental health interventions. We believe that many of the key feedback messages provided by these evaluation panels could prove useful to other digital mental health intervention designers.

Animal models to improve our understanding and treatment of suicidal behavior

Worldwide, suicide is a leading cause of death. Although a sizable proportion of deaths by suicide may be preventable, it is well documented that despite major governmental and international investments in research, education and clinical practice suicide rates have not diminished and are even increasing among several at-risk populations. Although nonhuman animals do not engage in suicidal behavior amenable to translational studies, we argue that animal model systems are necessary to investigate candidate endophenotypes of suicidal behavior and the neurobiology underlying these endophenotypes. Animal models are similarly a critical resource to help delineate treatment targets and pharmacological means to improve our ability to manage the risk of suicide. In particular, certain pathophysiological pathways to suicidal behavior, including stress and hypothalamic-pituitary-adrenal axis dysfunction, neurotransmitter system abnormalities, endocrine and neuroimmune changes, aggression, impulsivity and decision-making deficits, as well as the role of critical interactions between genetic and epigenetic factors, development and environmental risk factors can be modeled in laboratory animals. We broadly describe human biological findings, as well as protective effects of medications such as lithium, clozapine, and ketamine associated with modifying risk of engaging in suicidal behavior that are readily translatable to animal models. Endophenotypes of suicidal behavior, studied in animal models, are further useful for moving observed associations with harmful environmental factors (for example, childhood adversity, mechanical trauma aeroallergens, pathogens, inflammation triggers) from association to causation, and developing preventative strategies. Further study in animals will contribute to a more informed, comprehensive, accelerated and ultimately impactful suicide research portfolio.

The Microbiome of the Built Environment and Human Behavior: Implications for Emotional Health and Well-Being in Postmodern Western Societies

It is increasingly evident that inflammation is an important determinant of cognitive function and emotional behaviors that are dysregulated in stress-related psychiatric disorders, such as anxiety and affective disorders. Inflammatory responses to physical or psychological stressors are dependent on immunoregulation, which is indicated by a balanced expansion of effector T-cell populations and regulatory T cells. This balance is in part driven by microbial signals. The hygiene or "old friends" hypothesis posits that exposure to immunoregulation-inducing microorganisms is reduced in modern urban societies, leading to an epidemic of inflammatory disease and increased vulnerability to stress-related psychiatric disorders. With the global trend toward urbanization, humans are progressively spending more time in built environments, thereby, experiencing limited exposures to these immunoregulatory "old friends." Here, we evaluate the implications of the global trend toward urbanization, and how this transition may affect human microbial exposures and human behavior.

Hypogonadism on admission to acute rehabilitation is correlated with lower functional status at admission and discharge

PRIMARY OBJECTIVE

To investigate the association between hormone levels and functional status during acute TBI rehabilitation.

RESEARCH DESIGN

Retrospective cohort study of 43 men with moderate-to-severe TBI admitted to an acute rehabilitation unit during a 1 year period.

METHODS AND PROCEDURES

Labs were drawn on admission, including total and free testosterone (T), prolactin, adrenocorticotropin hormone (ACTH), cortisol, thyroid stimulating hormone (TSH), free thyroxine (fT4) and insulin-like growth factor (IGF-1). Functional Independence Measure (FIM) scores were obtained at admission and discharge.

MAIN OUTCOME AND RESULTS

Associations between admission hormone levels and the main outcomes, admission and discharge FIM scores, were assessed using linear regression. Lower total and free T-levels at admission were associated with lower total FIM scores at admission (p < 0.038) and discharge (p < 0.046). Higher cortisol levels at admission were significantly associated with lower admission (p = 0.012) and discharge (p = 0.036) scores on the cognitive-FIM. Prolactin, TSH, fT4 and IGF-1 were not correlated with functional status.

CONCLUSIONS

In men, lower total and free T-levels at admission to acute rehabilitation correlate with lower admission and discharge FIM scores. These data support the need for studies to investigate the impact of physiological testosterone therapy on outcomes during and post-rehabilitation.

Use of electrostimulation in the treatment of diabetic neuroarthropathy

Charcot's joint is a difficult and sometimes frustrating condition to treat, for both the patient and the physician. The authors give a brief overview of Charcot's joint and the treatment options available. They discuss the use of bone stimulators and how electrostimulation may be used to help arrest the progression of Charcot's deformity. To the authors' knowledge, the use of electrostimulation for the treatment of Charcot's joint has been described only once in the literature; three patients were evaluated in that study. In the current study, 11 patients were evaluated, with promising results obtained, thus supporting the findings of the previous study.

Subjective probability of disjunctive hypotheses: local-weight models for decomposition of evidential support

When the probability of a single member of a set of mutually exclusive and exhaustive possibilities is judged, its alternatives are evaluated as a composite "residual" hypothesis. Support theory (Rottenstreich & Tversky, 1997; Tversky & Koehler, 1994) implies that the process of packing alternatives together in the residual reduces the perceived evidential support for the set of alternatives and consequently inflates the judged probability of the focal hypothesis. Previous work has investigated the global weights that determine the extent to which the overall evidential support for the alternatives is discounted by this packing operation (Koehler, Brenner, & Tversky, 1997). In the present investigation, we analyze this issue in greater detail, examining the local weights that measure the specific contribution of each component hypothesis included implicitly in the residual. We describe a procedure for estimating local weights and introduce a set of plausible properties that impose systematic ordinal relationships among local weights. Results from four experiments testing these properties are reported, and a local-weight model is developed that accounts for nearly all of the variance in the probability judgments in these empirical tests. Local weights appear to be sensitive both to the individual component with which they are associated and to the residual hypothesis in which the component resides.

Intracerebroventricular cholecystokinin A-receptor antagonist does not reduce satiation by endogenous CCK

Suppression of sham feeding by exogenous CCK-8 or intraintestinal oleate infusion is attenuated by peripheral administration of the CCK-A receptor antagonist, devazepide, but not by the CCK-B antagonist, L365260. Likewise, systemically administered devazepide increases food intake by real feeding rats. These results suggest that endogenous CCK participates in the reduction of food intake by intestinal oleate and ingested food. Although originally categorized as a "peripheral" receptor subtype, the CCK-A receptor is also present in the brain. In an effort to examine whether devazepide acts in the brain or in the periphery to attenuate suppression of food intake by intraintestinal oleate, we injected devazepide into the lateral or fourth cerebral ventricles of intraintestinally infused, sham-fed rats. We also compared the ability of intracerebroventricular (i.c.v.) and intraperitoneal (i.p.) devazepide to elicit increased food intake in real feeding rats. Doses of devazepide that were sufficient to attenuate or abolish oleate-induced suppression of sham feeding, when administered i.p., failed to attenuate suppression of intake when administered i.c.v., i.p. devazepide also was more effective than i.c.v. devazepide for attenuation of the suppression of sham feeding by i.p. injection of exogenous CCK-8. Finally, i.c.v. devazepide was ineffective for increasing real food intake, whereas the same dose administered i.p. significantly increased food intake. Our results do not support participation of brain CCK-A receptors in the suppression of food intake by exogenous CCK, or by endogenous CCK released after intraintestinal oleate infusion, or food intake.

Type A CCK receptors mediate satiety effects of intestinal nutrients

Previous work indicates that endogenous CCK mediates suppression of sham feeding by some intraintestinal nutrients. To test whether the mechanism involved is dependent upon action at type A or type B CCK receptors, we examined the ability of CCKA (devazepide) and CCKB (L-365,260) receptor antagonists to attenuate the suppression of sham feeding by intraintestinal oleic acid, maltotriose, or L-phenylalanine. Suppression by oleic acid or maltotriose was dose dependently attenuated by intraperitoneal administration of the CCKA receptor antagonist, as was suppression by exogenous CCK. The CCKB receptor antagonist failed to attenuate the suppression of sham feeding by these nutrients. Neither receptor antagonist attenuated the suppression of sham feeding induced by intraintestinal L-phenylalanine. These results suggest that suppression of sham feeding by intestinally infused oleic acid and maltotriose is mediated by endogenous CCK acting at CCKA receptors.

Confidence and accuracy in trait inference: judgment by similarity

We examined the confidence and accuracy with which people make personality trait inferences and investigate some consequences of the hypothesis that such judgments are based on similarity or conceptual relatedness. Given information concerning a target person's standing on three global personality dimensions, American and Israeli subjects were asked to estimate the target's self-ratings of 50 trait adjectives and to express their confidence by setting a 90 percent uncertainty range around each estimate. The estimates were positively correlated with the actual ratings obtained from subjects who had evaluated themselves in terms of the 50 traits, but were far too extreme. Furthermore, confidence was negatively correlated with accuracy: People's estimates were most inaccurate and made with greatest certainty when the trait in question was highly similar to the information provided as a basic for judgment. We suggest that intuitive personality judgments overestimate the coherence of the structure underlying trait constructs.