Co-learning commentary: a patient partner perspective in mental health care research

BACKGROUND

Although including patients as full, active members of research teams is becoming more common, there are few accounts about how to do so successfully, and almost none of these are written by patient partners themselves. Three patient partners contributed their lived experience to a three-year, multi-component mental health research project in British Columbia, Canada. As patient partners, we contributed to innovative co-learning in this project, resulting in mutual respect and wide-ranging benefits. To guide future patient partners and researchers seeking patient engagement, we outline the processes that helped our research team 'get it right'.

MAIN BODY

From the outset, we were integrated into components of the project that we chose: thematically coding a rapid review, developing questions and engagement processes for focus groups, and shaping an economic model. Our level of engagement in each component was determined by us. Additionally, we catalyzed the use of surveys to evaluate our engagement and the perceptions of patient engagement from the wider team. At our request, we had a standing place on each monthly meeting agenda. Importantly, we broke new ground when we moved the team from using previously accepted psychiatric terminology that no longer fit the reality of patients' experiences. We worked diligently with the team to represent the reality that was appropriate for all parties. The approach taken in this project led to meaningful and successfully integrated patient experiences, fostered a shared understanding, which positively impacted team development and cohesion. The resulting 'lessons learned' included engaging early, often, and with respect; carving out and creating a safe place, free from stigma; building trust within the research team; drawing on lived experience; co-creating acceptable terminology; and cultivating inclusivity throughout the entire study.

CONCLUSION

We believe that lived experience can and should go hand-in-hand with research, to ensure study outcomes reflect the knowledge of patients themselves. We were willing to share the truth of our lived experience. We were treated as co-researchers. Successful engagement came from the 'lessons learned' that can be used by other teams who wish to engage patient partners in health research.

Home-based and community-based activities that can improve mental wellness: a protocol for an umbrella review

INTRODUCTION

Mental disorders affect about 13% of the world's population. While evidence-based mental health treatments are available, a significant number of persons with mental illnesses are untreated or do not receive adequate mental healthcare due to various reasons, including costs, stigma and the desire to self-manage symptoms. In the past few years, there has been an increase in the body of evidence regarding leisure activities and mental wellness. However, there is currently no published overview of the state of the evidence on these activities and their potential preventive and therapeutic effects on mental health.

METHODS AND ANALYSIS

Using Joanna Briggs Institute (JBI) review guidelines, an umbrella review will be undertaken to synthesise findings from systematic reviews and meta-analyses on the mental health benefits of home-based and community-based activities. MEDLINE, PsycInfo, Embase, CINAHL, Web of Science, Epistemonikos, Cochrane Database of Systematic Reviews, JBI Database of Systematic Reviews and Implementation Reports will be searched for potentially relevant systematic reviews and meta-analyses published from January 1991 to present. Title/abstract screening, full-text review, data extraction and assessment of methodological quality will each be performed independently by two reviewers. A third review author will be available to resolve discrepancies in any of the review tasks. To assess the quality of potentially eligible reviews, the JBI Critical Appraisal Checklist for Systematic Reviews and Research Syntheses will be used. Findings will be presented in table form and will be summarised by study population, type of home-based or community-based activity or intervention, and type of mental health outcomes. Overall assessment of the strength of existing evidence from eligible systematic reviews will be provided following the grading of recommendation, assessment, development and evaluation approach.

ETHICS AND DISSEMINATION

No ethical approval is required. Results of this umbrella review will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42021266989.

Pharmacogenomic Testing for Major Depression: A Qualitative Study of the Perceptions of People with Lived Experience and Professional Stakeholders

OBJECTIVES

With increasing evidence for the clinical utility of pharmacogenomic (PGx) testing for depression, there is a growing need to consider issues related to the clinical implementation of this testing. The perspectives of key stakeholders (both people with lived experience [PWLE] and providers) are critical, but not frequently explored. The purpose of this study was to understand how PWLE and healthcare providers/policy experts (P/HCPs) perceive PGx testing for depression, to inform the consideration of clinical implementation within the healthcare system in British Columbia (BC), Canada.

METHODS

We recruited two cohorts of participants to complete individual 1-h, semi-structured interviews: (a) PWLE, recruited from patient and research engagement networks and organizations and (b) P/HCPs, recruited via targeted invitation. Interviews were audiotaped, transcribed verbatim, de-identified, and analysed using interpretive description.

RESULTS

Seventeen interviews were completed with PWLE (7 with experience of PGx testing for depression; 10 without); 15 interviews were completed with P/HCPs (family physicians, psychiatrists, nurses, pharmacists, genetic counsellors, medical geneticists, lab technologists, program directors, and insurers). Visual models of PWLE's and P/HCP's perceptions of and attitudes towards PGx testing were developed separately, but both were heavily influenced by participants' prior professional and/or personal experiences with depression and/or PGx testing. Both groups expressed a need for evidence and numerous considerations for the implementation of PGx testing in BC, including the requirement for conclusive economic analyses, patient and provider education, technological and clinical support, local testing facilities, and measures to ensure equitable access to testing.

CONCLUSIONS

While hopeful about the potential for therapeutic benefit from PGx testing, PWLE and P/HCPs see the need for robust evidence of utility, and BC-wide infrastructure and policies to ensure equitable and effective access to PGx testing. Further research into the accessibility, effectiveness, and cost-effectiveness of various implementation strategies is needed to inform PGx testing use in BC.

A patient-oriented analysis of pain side effect: A step to improve the patient's experience during rTMS?

BACKGROUND

Repetitive transcranial magnetic stimulation (rTMS) is an efficacious and well-tolerated intervention for treatment-resistant depression (TRD). A novel rTMS protocol, intermittent theta burst stimulation (iTBS) has been recently implemented in clinical practice, and it is essential to characterize the factors associated to pain and the trajectory of pain of iTBS compared to standard rTMS protocols.

OBJECTIVE

We aimed to characterize the side effect profile and the pain trajectories of High-Frequency Left (HFL) and iTBS in TRD patients in the THREE-D trial. We also investigated factors associated to pain and the relationship between pain and clinical outcomes.

METHODS

414 patients were randomized to either HFL or iTBS. Severity of pain was measured after every treatment. General Estimating Equation was used to investigate factors associated with pain. Latent class linear mixed model was used to investigate latent classes of pain trajectories over the course of rTMS.

RESULTS

Higher level of pain was associated with older age, higher stimulation intensity, higher anxiety, female, and non-response. The severity of pain significantly declined over the course of treatments with a steeper decrease early on in the course of the treatment in both protocols, and four latent pain trajectories were identified. The less favorable pain trajectories were associated with non-response and higher stimulation intensity.

CONCLUSIONS

HFL and iTBS were associated with similar factors and pain trajectories, although iTBS was more uncomfortable. Response to rTMS was associated with less pain and more favorable pain trajectories furthering the evince base of overlapping neurobiological underpinnings of mood and pain. We translated these results into patient-oriented information to aid in the decision-making process when considering rTMS.

Patient oriented research in mental health: matching laboratory to life and beyond in Canada

As patient-oriented research gains popularity in clinical research, the lack of patient input in foundational science grows more evident. Research has shown great utility in active partnerships between patient partners and scientists, yet many researchers are still hesitant about listening to the voices of those with lived experience guide and shape their experiments. Mental health has been a leading area for patient movements such as survivor-led research, however the stigma experienced by these patients creates difficulties not present in other health disciplines. The emergence of COVID-19 has also created unique circumstances that need to be addressed. Through this lens, we have taken experiences from our patient partners, students, and primary investigator to create recommendations for the better facilitation of patient-oriented research in foundational science in Canada. With these guidelines, from initial recruitment and leading to sustaining meaningful partnerships, we hope to encourage other researchers that patient-oriented research is necessary for the future of mental health research and foundational science.

P4-07-08: Subsets and Molecular Signatures of Circulating Tumor Cells in Breast Cancer Brain Metastasis

Background: Circulating tumor cells (CTCs) represent the “seeds” of intractable brain metastatic breast cancer (BMBC); however, properties of CTCs targeting the brain remain elusive. For example, the FDA-approved CTC platform (CellSearch™, Veridex, LLC) detects only CTCs positive for epithelial cell adhesion molecule (EpCAM) and cytokeratins (CKs), but is unable to capture any other CTC subtypes or analyze biomarkers of brain-homing CTCs. We hypothesized that profiling CTCs from BMBC patients might result in the identification of brain-colonizing CTC signatures. Materials and Methods: We employed CellSearch™ and a novel technology that uses analysis of specific antigenic markers by immunofluorescence, coupled with detecting gene amplification by fluorescence in situ hybridization on the same cells; and quantification of the signal via automated scanning (FICTION; BioView Duet-3™ system).

Results: We established that our approach was feasible by performing CTC analyses on peripheral blood mononuclear cells isolated from BMBC patients or patients not possessing overt metastatic disease. We detected a differential gene amplification for human epidermal growth factor receptor1 and 2 (EGFR and HER2, respectively). Second, the number of EpCAM-positive CTCs visualized by the BioView™ platform was at least three orders of magnitude higher than one obtained from CellSearch™ CTC analyses using the same specimen. Third, we identified the presence of CTCs positive for CKs but negative for EpCAM. Conversely, high levels of prometastatic heparanase, in conjunction with the expression of aldehyde dehydrogenase-1 (ALDH1), a known cancer stem-cell marker, were detected in CTCs from BMBC patients; with a correlation between heparanase, ALDH1, and high EGFR amplification. Finally, extensive flow cytometric/FACS analyses validated the presence of CTC subsets negative for EpCAM and CD45, a hematolymphoid marker, however enriched for heparanase/ALDH1 expression.

Discussion: These findings indicate that the BioView™ platform not only captures more EpCAM-positive CTCs than CellSearch™ but also allows the detection of novel CTC subtypes possessing varying EpCAM levels. Importantly, they suggest that profiling CTC subtypes in patients with BMBC can be relevant towards the discovery of BMBC founder CTCs. Work is ongoing to further characterize these CTC subtypes, and to assess their abilities to metastasize to brain in xenotransplantation studies using immunodeficient mice.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-07-08.

Is fetal heart rate variability a good predictor of fetal outcome?

OBJECTIVE

The purpose of this study was to investigate, in a prospective manner, whether fetal heart rate (FHR) variability serves as a reliable single predictor of fetal outcome.

METHODS

We undertook a prospective study of 2,200 consecutive deliveries. Preterms < 37 weeks, twins, stillbirths and fetal malformations were excluded from the study. FHR tracings were analyzed for variability in every delivery. Three windows were evaluated: 1) early in labor (30 min); 2) in the active phase of labor - 1 h prior to complete cervical dilatation (30 min); and 3) throughout the second stage of delivery, in segments of 30 min. Using the tracings taken at admission and prior to delivery, FHR variability was scored according to five previously used evaluative methods, and was correlated to the following three fetal outcome parameters: a) arterial cord blood pH < 7.2, > 7.2; b) 5-min Apgar >6, < 7; and c) immediate outcome ('good' defined as newborn going home after 2-5 days, with no neonatal intensive care unit (NICU) admission).

RESULTS

1. The majority of cases with adverse fetal outcome exhibited good FHR variability (mean, 80%). 2. Low FHR variability is not common in newborns with adverse general outcome (mean, 11.5%). 3. The predictability of FHR variability (using the five most common scoring methods) for evaluating adverse fetal outcome revealed low sensitivity (mean, 20.3%) and low predictive value (mean, 11.6%).

CONCLUSION

FHR variability by itself cannot serve as the only indicator of fetal wellbeing. The presence of low variability should alert the physician; however, good FHR variability should not be interpreted as reassuring.