A longitudinal study of the impacts of a stay in a Prevention and Recovery Care service in Victoria, Australia

BACKGROUND

Prevention and Recovery Care services are residential sub-acute services in Victoria, Australia, guided by a commitment to recovery-oriented practice. The evidence regarding the effectiveness of this service model is limited, largely relying on small, localised evaluations. This study involved a state-wide investigation into the personal recovery, perceived needs for care, well-being and quality-of-life outcomes experienced by Prevention and Recovery Care services' consumers.

METHODS

A longitudinal cohort design examined the trajectory of self-reported personal recovery and other outcomes for consumers in 19 Victorian Prevention and Recovery Care services over 4 time points (T1 - 1 week after admission; T2 - within 1 week of discharge; T3 - 6 months after discharge; T4 - 12 months after discharge). T2-T4 time frames were extended by approximately 3 weeks due to recruitment challenges. The Questionnaire about the Process of Recovery was the primary outcome measure.

RESULTS

At T1, 298 consumers were recruited. By T4, 114 remained in the study. Participants scored higher on the Questionnaire about the Process of Recovery at all three time points after T1. There were also sustained improvements on all secondary outcome measures. Improvements were then sustained at each subsequent post-intervention time point. Community inclusion and having needs for care met also improved.

CONCLUSION

The findings provide a consistent picture of benefits for consumers using Prevention and Recovery Care services, with significant improvement in personal recovery, quality of life, mental health and well-being following an admission to a Prevention and Recovery Care service. Further attention needs to be given to how to sustain the gains made through a Prevention and Recovery Care service admission in the long term.

Consumers lived experiences and satisfaction with sub-acute mental health residential services

PURPOSE

Sub-acute recovery-oriented facilities offer short-term residential support for people living with mental illness. They are generally highly regarded by consumers, with emerging evidence indicating that these services may support recovery. The aim of the current study was to explore the relationship between personal recovery and consumers' satisfaction with sub-acute residential services, and consumers' views about service features that aid recovery.

METHODS

Consumers at 19 adult Prevention and Recovery Care Services in Victoria, Australia, were invited to complete measures containing sociodemographic information and measures on personal recovery and wellbeing. After going home, participants were invited to complete measures on service satisfaction and experience.

RESULTS

Total and intrapersonal scores on the personal recovery measure increased significantly between Time 1 and Time 2, indicating marked improvement. Personal recovery and satisfaction measures were moderately to strongly correlated. Thematically analysed open-ended responses revealed themes of feeling connected, finding meaning and purpose, and self-empowerment as important aspects of these services, with some recommendations for improvements.

CONCLUSION

Sub-acute residential mental health care may support individuals' personal recovery; consumer satisfaction indicates these services also offer an acceptable and supportive environment for the provision of recovery-oriented care. Further exploring consumers' experiences of sub-acute residential services is essential to understand their effectiveness, opportunities for improvement and intended impacts on personal recovery.

Early intervention to prevent adverse child emotional and behavioural development following maternal depression in pregnancy: study protocol for a randomised controlled trial

BACKGROUND

Substantial evidence indicates that maternal depression during pregnancy (i.e., antenatal depression) is associated not only with maternal wellbeing but also with child emotional and behavioural development. Children of antenatally depressed women are at risk of emotional and behavioural problems, including internalising problems (e.g., anxiety and depression) and externalising problems (e.g., attention problems), that may last at least to adolescence. These enduring effects also constitute an enormous economic cost. Despite the seriousness of this problem, until recently there existed very few controlled studies evaluating whether active psychological treatment for antenatal depression can prevent adverse child outcomes. Our previous pilot randomised controlled trial (RCT) exploring the effect of cognitive behavioural therapy (CBT) for antenatal depression on child outcomes showed promising results. We aim to assess whether treating antenatal depression with an evidence-based 8-week structured CBT program can prevent or ameliorate adverse child developmental outcomes at 2 years of age.

METHODS

Pregnant women ≤ 30 weeks gestation diagnosed with a depressive disorder are recruited and randomised to CBT or treatment as usual (TAU). The target sample size is 230 and the primary outcome measure is the infant Internalising scale of the Child Behaviour Checklist (CBCL) at 24 months of age. Secondary infant outcome measures at 24 months are the Externalising scale of the CBCL and the motor and cognitive development subscales of the Ages & Stages Questionnaire (ASQ-3). Additional secondary outcome measures are subscales of the Revised Infant Behaviour Questionnaire (IBQ-R), ASQ-3 and the ASQ-Socio-Emotional (ASQ-SE) at 3 and 12 months of age and the quality of mother-infant interaction at 3 and 24 months. Maternal measures, including demographic data, depression diagnosis, depressive and anxiety symptoms, perceived stress and parenting stress, are collected across all time points.

DISCUSSION

The trial is ongoing and recruitment was slowed due to the COVID-19 pandemic. If results suggest a beneficial effect of antenatal depression treatment on infant outcomes, the project could have repercussions for standard antenatal care, for maternal and infant health services and for preventing the intergenerational transmission of mental health disorders.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Register: ACTRN12618001925235 Date Registered: 27 November 2018.

Gender differences in eating disorder-related intrusive thoughts

The present study aimed to examine gender differences in the experience of eating disorder-related intrusive thoughts (EDITs; i.e., frequency, content, emotional consequences, & control strategies). In addition, differences in the experience of EDITs across those atrisk of developing an eating disorder and those who are not atrisk were investigated. Six hundred and seventy-one adults completed self-report measures assessing the experience of EDITs, disordered eating attitudes and behaviours, and body dissatisfaction. It was found that females experienced EDITs more frequently and with higher levels of distress compared with males. With regard to control strategies, females tended to use distraction and thought suppression, whereas males were likely to do nothing in response. Participants in the at-risk group experienced EDITs more frequently, with higher distress, and responded by using obsessive-compulsive rituals or doing what the intrusion dictated significantly more than non-risk participants. Relationships between body dissatisfaction and EDITs related to bodily appearance were found to be stronger for men, whereas women revealed a stronger relationship between disordered eating and purging EDITs. The findings of this study support the growing literature regarding EDITs as a distinct clinical feature of eating disorders, and the developing evidence base regarding intrusive thoughts as a transdiagnostic mechanism.

The feasibility of an online educational lifestyle program for people with multiple sclerosis: A qualitative analysis of participant semi-structured interviews

Objective

To explore the feasibility of a randomised controlled trial of a multiple sclerosis online course (MSOC) via qualitative analysis of participant semi-structured interviews.

Methods

The MSOC was developed in two arms: intervention arm which contained evidence-based lifestyle modification recommendations, and standard-care arm which delivered information from MS websites reflecting standard advice. Participants were recruited via online advertisements, completed a baseline questionnaire, and randomised. Seven modules were delivered over six weeks. Course completers were invited to participate in semi-structured interviews. Within a qualitative paradigm, interviews were analysed using reflexive thematic analysis.

Results

Fourteen of the 17 course completers were interviewed: 86% (12/14) female; mean age 50 years; residing in Australia, New Zealand, and the USA, predominantly had relapsing-remitting MS, mean time from diagnosis 9.5 years, and patient-determined disease steps disability assessment distributed evenly across all three categories. Four themes were identified: 1) “Hearing our stories” (hope for the future, feeling represented, exploring the journey of others with MS, learning from diversity, and wanting to connect with others); 2) “Taking the plunge” (not wanting to be first, feelings of nervousness or reluctance and feeling confronted); 3) “The accessibility and safety of being online” (ease of access, going at your own pace, making it work and not letting others down); and 4) “unpacking the course” (ease of navigation, visuals, understandability, and length and timing).

Conclusion

Participants felt represented, found the course accessible and content was easy to understand. These experiences provide important insights and considerations for this digital health intervention.

Integrating headache trigger management strategies into cognitive-behavioral therapy: A randomized controlled trial

OBJECTIVE

Traditionally, the standard advice to individuals suffering from migraine and tension-type headache was that the best way to prevent headaches is to avoid the triggers. This advice has been challenged in recent years and the Trigger Avoidance Model of Headache has been proposed, which suggests that one pathway to developing a headache disorder is by avoiding triggers resulting in trigger sensitization. The objective of the study was to evaluate a novel intervention for primary headache comprising a new approach to trigger management that includes exposure to some triggers with the goal of trigger desensitization (learning to cope with triggers [LCT]) integrated into a cognitive-behavioral therapy (CBT) program (LCT/CBT).

METHOD

The study was a randomized controlled trial comparing LCT/CBT to the same treatment program but using the traditional approach to trigger management of encouraging trigger avoidance (avoid/CBT), and to a waiting-list/treatment-as-usual control condition (WL/TAU). Adults suffering from primary headache (88 female/35 male) were allocated to the three conditions.

RESULTS

The three groups significantly differed from baseline to posttreatment on the primary outcome measure of attack frequency, and LCT/CBT significantly differed from WL/TAU but Avoid/CBT did not. Similar results were obtained on the secondary outcome measures, and treatment gains were maintained at 4- and 12-month follow-up.

CONCLUSIONS

The results suggest the value of using LCT as a component of a CBT program but were not conclusive as the direct comparisons between the two treatment conditions failed to reach statistical significance. The findings support a study of LCT/CBT with a larger sample. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Outcomes of Victorian Prevention and Recovery Care Services: A matched pairs comparison

OBJECTIVE

In Victoria, Prevention and Recovery Care Services have been established to provide a partial alternative to inpatient admissions through short-term residential mental health care in the community. This study set out to determine whether Prevention and Recovery Care Services are achieving their objectives in relation to reducing service use and costs, fostering least restrictive care and leading to positive clinical outcomes.

METHODS

We matched 621 consumers whose index admission in 2014 was to a Prevention and Recovery Care ('PARCS consumers') with 621 similar consumers whose index admission in the same year was to an acute inpatient unit and who had no Prevention and Recovery Care stays for the study period ('inpatient-only consumers'). We used routinely collected data to compare them on a range of outcomes.

RESULTS

Prevention and Recovery Care Services consumers made less subsequent use of acute inpatient services and, on balance, incurred costs that were similar to or lower than inpatient-only consumers. They were also less likely to spend time on an involuntary treatment order following their index admission. Prevention and Recovery Care Services consumers also experienced positive clinical outcomes over the course of their index admission, but the magnitude of this improvement was not as great as for inpatient-only consumers. This type of clinical improvement is important for Prevention and Recovery Care Services, but they may place greater emphasis on personal recovery as an outcome.

CONCLUSION

Prevention and Recovery Care Services can provide an alternative, less restrictive care option for eligible consumers who might otherwise be admitted to an acute inpatient unit and do so at no greater cost.

Treating enuresis in children with neurodevelopmental disorders using bell and pad alarm

OBJECTIVE

There is a high prevalence of enuresis in children with neurodevelopmental disorders, yet research regarding treatment for this group has been neglected. The efficacy of treatment using bell and pad alarm therapy is not well reported especially in children with neurodevelopmental disorders. This study sought to compare the treatment efficacy of practitioner-assisted bell-and-pad enuresis alarm therapy for children with neurodevelopmental disorders and typically developing children.

STUDY DESIGN

This study utilized the data of Apos et al. (2018), a retrospective medical record audit collected from multiple clinical settings across Australia. A total of 2986 patient records (3659 treatment records) were included. The participants were children aged 5-16 years, who were diagnosed with enuresis. Children with a neurodevelopmental disorder (n = 158) had a clinical diagnosis present in the medical history of attention deficit disorder, autism spectrum disorder, or intellectual disability. Children who indicated any of the following comorbidities were excluded: cerebral palsy, brain injury, malformation of the renal tract, previous bladder or renal surgery, spinal cord malformation, spinal cord trauma or tumor, or a neurodegenerative disorder. Treatment success was defined as ≥ 14 dry nights. Relapse was defined as one symptom recurrence per month post-interruption of treatment, as defined by the International Children's Continence Society definitions.

RESULTS

The success rate for children with neurodevelopmental disorders was 62% and typically developing children was 78%. There was no significant difference between the number of treatments received or relapse rates by those children with a neurodevelopmental disorder and typically developing children. The summary figure shows the percentage of children in each group after their first treatment who were successful (success defined as dry for ≥ 14 days), who succeeded (dry for ≥ 14 days) but then relapsed and those who showed no success. The percentage of children with no NDD who were successfully dry after the first treatment was 78%. Children with ID had success after the first treatment of 59%, the lowest of all groups analyzed.

CONCLUSION

The type of alarm therapy reported in this study is effective for treating enuresis in children with neurodevelopmental disorders.

Transcranial magnetic stimulation as a treatment for posttraumatic stress disorder: A meta-analysis

BACKGROUND

Posttraumatic stress disorder (PTSD) is a pervasive mental health condition with limited treatment success. Transcranial magnetic stimulation (TMS) has shown positive outcomes for people with PTSD, using different treatment protocols. This meta-analysis sought to examine which variables in TMS treatment are associated with treatment benefits.

METHODS

A literature search of major online research databases from inception to September 15, 2020 was conducted to identify primary research studies using TMS to treat PTSD. Treatment effect data and TMS treatment variables were coded and analysed using a random effects model. Meta-regression and analyses of moderating variables were conducted to ascertain which variables were associated with significant treatment effects.

RESULTS

An overall effect size of d = 1.17, 95% CI [0.89 - 1.45] for TMS as a treatment for PTSD was found. Analysis of moderators showed that there was a significantly larger treatment effect for high frequency TMS (d = 1.44) compared with low frequency (d = 0.72), p = .006; there was no significant difference between TMS targeting the left dorsolateral prefrontal cortex (DLPFC) and the right DLPFC; and larger treatment doses were not associated with stronger treatment effects.

LIMITATIONS

Not all published studies were available in English or reported the necessary data to be included in this meta-analysis.

CONCLUSIONS

TMS shows potential as a treatment for PTSD, although further research is required to understand the neurological mechanisms of TMS on specific PTSD symptoms so that more effective treatment can be designed for individuals.

The impact of ileal pouch-anal anastomosis on graft survival following liver transplantation for primary sclerosing cholangitis

BACKGROUND

Liver transplantation is the only life-extending intervention for primary sclerosing cholangitis (PSC). Given the co-existence with colitis, patients may also require colectomy; a factor potentially conferring improved post-transplant outcomes.

AIM

To determine the impact of restorative surgery via ileal pouch-anal anastomosis (IPAA) vs retaining an end ileostomy on liver-related outcomes post-transplantation.

METHODS

Graft survival was evaluated across a prospectively accrued transplant database, stratified according to colectomy status and type.

RESULTS

Between 1990 and 2016, 240 individuals with PSC/colitis underwent transplantation (cumulative 1870 patient-years until first graft loss or last follow-up date), of whom 75 also required colectomy. A heightened incidence of graft loss was observed for the IPAA group vs those retaining an end ileostomy (2.8 vs 0.4 per 100 patient-years, log-rank P = 0.005), whereas rates between IPAA vs no colectomy groups were not significantly different (2.8 vs 1.7, P = 0.1). In addition, the ileostomy group experienced significantly lower graft loss rates vs. patients retaining an intact colon (P = 0.044). The risks conferred by IPAA persisted when taking into account timing of colectomy as related to liver transplantation via time-dependent Cox regression analysis. Hepatic artery thrombosis and biliary strictures were the principal aetiologies of graft loss overall. Incidence rates for both were not significantly different between IPAA and no colectomy groups (P = 0.092 and P = 0.358); however, end ileostomy appeared protective (P = 0.007 and 0.031, respectively).

CONCLUSION

In PSC, liver transplantation, colectomy + IPAA is associated with similar incidence rates of hepatic artery thrombosis, recurrent biliary strictures and re-transplantation compared with no colectomy. Colectomy + end ileostomy confers more favourable graft outcomes.

Enuresis Management in Children: Retrospective Clinical Audit of 2861 Cases Treated with Practitioner-Assisted Bell-and-Pad Alarm

OBJECTIVE

To establish the treatment efficacy of practitioner-assisted bell-and-pad alarm therapy in children with enuresis between the ages of 5 and 16 years by retrospective medical chart review of 2861 children in multiple clinical settings.

STUDY DESIGN

This review was conducted across 7 Australian clinical practices. The primary outcome measure was the time taken for children with either primary, secondary, monosymptomatic, or nonmonosymptomatic enuresis to be dry for 14 consecutive nights. The secondary outcome measure was to determine relapse rates, defined as 1 symptom recurrence per month post interruption of treatment. Data were analyzed by correlation and χ² test via IBM SPSS Statistics (version 22).

RESULTS

The overall success rate of the bell and pad treatment was 76%, irrespective of age. The mean treatment time to achieve dryness was 62.1 ± 30.8 days, and the relapse rate was 23%. Concurrent bowel dysfunction was associated with a slightly lower success rate (74%). Concurrent lower urinary tract symptoms were associated with a lower success rate (73%) and greater relapse (1.75 times more likely to relapse). Children with secondary enuresis had significantly greater success than those with primary enuresis (82% vs 74%).

CONCLUSION

The type of alarm therapy reported in this study is highly effective. This study will provide the basis for clinical guidelines and practice tools for clinicians, which will help to reduce variation in care pathways for alarm treatment for enuresis.

The relationship between chronotype and depressive symptoms: A meta-analysis

BACKGROUND

Expanding our understanding of the factors that influence depression is crucial for prognosis and treatment. In light of increasing evidence of an association between disrupted circadian rhythms and affective symptoms, a meta-analysis was used to examine the relationship between an eveningness chronotype and depression.

METHODS

Electronic searches of the PsycINFO, Medline, Scopus, and Google Scholar databases were conducted in February 2016. Relevant reviews, related journals, and reference lists were manually searched. Statistical data were reported or transformed to a Fisher's z correlational coefficient for effect size analysis.

RESULTS

Data from 36 studies (n =15734) met the inclusion criteria and were analysed under a random effects model. Nearly all included studies utilised the Composite Scale of Morningness (CSM) or the Morningness-Eveningness Questionnaire (MEQ) as a measure of chronotype. Overall effect size from 58 effect sizes was small (z=-.20; 95% CI: -.18 to -.23). Effect sizes based on the CSM were significantly larger than those based on the MEQ. There was no evidence of publication bias.

LIMITATIONS

The number of studies comparing different mood disorders or the potential moderating effects of gender and age were too few to draw conclusions regarding their respective effect sizes. Future research should utilise longitudinal designs to draw causal inferences on the directionality of this relationship.

CONCLUSIONS

Findings from this meta-analysis indicate an eveningness orientation is somewhat associated with more severe mood symptoms. Chronobiological approaches may contribute to the prevention and treatment of depressive disorders.

The Impact of Tic Severity, Comorbidity and Peer Attachment on Quality of Life Outcomes and Functioning in Tourette's Syndrome: Parental Perspectives

The aim of this controlled, community-based study based on data from parents of youth (aged 7-16 years) with Tourette's syndrome (TS; n = 86) and parents of age and gender matched peers (n = 108) was to test several hypotheses involving a range of variables salient to the TS population, including peer attachment, quality of life, severity of tics, comorbidity, and psychological, behavioural and social dysfunction. Multivariate between-group analyses confirmed that TS group youth experienced lower quality of life, increased emotional, behavioural and social difficulties, and elevated rates of insecure peer attachment relative to controls, as reported by their primary caregiver. Results also confirmed the main hypothesis that security of peer attachment would be associated with individual variability in outcomes for youth with TS. As predicted, multivariate within-TS group analyses determined strong relationships among adverse quality of life outcomes and insecure attachment to peers, increased tic severity, and the presence of comorbid disorder. Findings suggest that youth with TS are at increased risk for insecure peer attachment and that this might be an important variable impacting the quality of life outcomes for those diagnosed.

Real-time driver drowsiness feedback improves driver alertness and self-reported driving performance

Driver drowsiness has been implicated as a major causal factor in road accidents. Tools that allow remote monitoring and management of driver fatigue are used in the mining and road transport industries. Increasing drivers' own awareness of their drowsiness levels using such tools may also reduce risk of accidents. The study examined the effects of real-time blink-velocity-derived drowsiness feedback on driver performance and levels of alertness in a military setting. A sample of 15 Army Reserve personnel (1 female) aged 21-59 (M=41.3, SD=11.1) volunteered to being monitored by an infra-red oculography-based Optalert Alertness Monitoring System (OAMS) while they performed their regular driving tasks, including on-duty tasks and commuting to and from duty, for a continuous period of 4-8 weeks. For approximately half that period, blink-velocity-derived Johns Drowsiness Scale (JDS) scores were fed back to the driver in a counterbalanced repeated-measures design, resulting in a total of 419 driving periods under "feedback" and 385 periods under "no-feedback" condition. Overall, the provision of real-time feedback resulted in reduced drowsiness (lower JDS scores) and improved alertness and driving performance ratings. The effect was small and varied across the 24-h circadian cycle but it remained robust after controlling for time of day and driving task duration. Both the number of JDS peaks counted for each trip and their duration declined in the presence of drowsiness feedback, indicating a dynamic pattern that is consistent with a genuine, entropy-reducing feedback mechanism (as distinct from random re-alerting) behind the observed effect. Its mechanisms and practical utility have yet to be fully explored. Direct examination of the alternative, random re-alerting explanation of this feedback effect is an important step for future research.

The relationships among self-care, dispositional mindfulness, and psychological distress in medical students

BACKGROUND

Past research suggests that medical students experience high levels of psychological distress.

OBJECTIVE

The aim of the current study was to investigate the relationships among engagement in self-care behaviours, dispositional mindfulness, and psychological distress.

METHODS

The sample consisted of 139 female and 68 male Australian medical students (N=207) aged 17-41 years (M=21.82, SD=3.62) across the 5 years of the Monash University medical course. Participants completed an online survey comprising a demographics questionnaire, the Five Facet Mindfulness Questionnaire, the Health-Promoting Lifestyle Profile II, and the Depression, Anxiety, and Stress Scales.

RESULTS

Results revealed significant and interpretable multivariate correlations between distress and both mindfulness and self-care. Furthermore, the dispositional mindfulness observation subscale was found to be a significant moderator of the relationship between several dimensions of self-care and psychological distress.

CONCLUSIONS

The present study points to the potential of self-care and mindfulness to decrease medical student distress and enhance well-being.

Treatment of postnatal depression with cognitive behavioural therapy, sertraline and combination therapy: a randomised controlled trial

OBJECTIVES

Both antidepressant medications and psychological therapy are common treatments for depression in postpartum women. Antidepressant treatment may have a number of practical disadvantages, including a preference by women to avoid medication while breastfeeding. Consequently, more information about the relative benefits of the two modalities in the perinatal period is helpful. In the treatment of depressive disorders there is some evidence that combination therapies (pharmacological plus psychological treatment) may be more efficacious than either form of mono-therapy in isolation. However, in the treatment of postnatal depression, such evidence is limited.

METHOD

Forty five postpartum women with a DSM-IV diagnosis of depression were randomised to receive either: 1) cognitive behavioural therapy (CBT); 2) sertraline, or 3) a combination of both treatment modalities. Psychometric measures were collected weekly for 12 weeks, with a follow-up at 24 weeks.

RESULTS

Symptoms of depression and anxiety were reduced to a significant degree following all three treatments. CBT mono-therapy was found to be superior to both sertraline mono-therapy and combination therapy after 12 weeks. The CBT mono-therapy group appeared to display the most rapid initial gains after treatment commencement.

CONCLUSIONS

In this sample, a specialised CBT program for postnatal depression was found to be superior as a mono-therapy compared to sertraline, a commonly prescribed SSRI antidepressant. This is in contrast to previous studies which have found no detectable difference in the efficacies of drug and psychological treatment for postnatal depression. Unlike some previous work, this study allowed a statistically independent evaluation of CBT mono-therapy for postnatal depression compared to both antidepressant and combination therapy. In line with previous studies in postpartum women, there was no detectable advantage of combining pharmacological and psychological treatments in the short term.

Maladaptive schemas in adolescent females with anorexia nervosa and implications for treatment

Recent research has highlighted the presence of Young's Early Maladaptive Schemas (EMSs) in individuals with an eating disorder (ED). This study assessed the EMSs reported by adolescent females with Anorexia Nervosa (AN) compared with a community group. Thirty-six adolescent females diagnosed with AN or subthreshold AN and 111 female secondary school students completed a questionnaire that included the Young Schema Questionnaire, the Behavior Assessment System for Children Self-report of Personality, and the Eating Disorder Screen for Primary Care. Two independent AN subtypes and two community subtypes were derived from responses to the questionnaire, and significant differences between the four comparison groups were found. High Pathology AN participants reported the highest level of psychological maladjustment. Social Isolation and Emotional Inhibition appeared to be most characteristic of adolescent AN in this sample. The results suggest that EMSs may require attention in the treatment of AN in adolescent females, and that different AN subtypes may require individualized treatment approaches.

Enhancing cognitive-behavioural therapy for recurrent headache: design of a randomised controlled trial

Background

We have argued against the traditional approach of counselling avoidance of all triggers of headaches and migraine. Problems with this approach include the impossibility of avoiding all triggers and the high costs associated with trying to do so, and that avoidance could lead to reduced tolerance for the triggers. We have developed an alternative approach called Learning to Cope with Triggers (LCT) that encourages avoidance of triggers that are detrimental to health and wellbeing, but uses exposure to other triggers to desensitise headache sufferers to the triggers. This approach has been shown to be more effective than advising avoidance of all triggers. Trigger management is only one component of a comprehensive treatment program and the current study is designed to evaluate a new approach to treating headaches in which LCT has been integrated into an established cognitive-behavioural therapy (CBT) package (LCT/CBT).

Methods/Design

A target sample of 120 adult participants who suffer from migraine or tension-type headache, at least six days per month, and have done so for at least 12 months will be recruited. Participants will be randomly assigned to one of three groups: LCT/CBT; Avoid/CBT (CBT combined with instructions to avoid all triggers); and waiting-list control. Measures will include: daily diaries for recording headaches, triggers and medication consumption; headache disability and quality of life; trigger avoidance; locus of control and self-efficacy; and coping strategies. Treatment will involve 12 60-minute sessions scheduled weekly. Assessment will be completed before and after treatment, and at 4 and 12 month follow-up. The data will be analysed to determine which approach is most effective, and predictors of response to treatment.

Discussion

Migraine and tension-type headache are common and can be disabling. CBT has been demonstrated to be an efficacious treatment for both disorders. However, there is room for improvement. This study aims to increase the efficacy of behavioural approaches and identify factors predictive of a positive response.

Trial registration

Australian and New Zealand Clinical Trials Registry ACTRN12614000435684.

An explorative study of metabolic responses to mental stress and yoga practices in yoga practitioners, non-yoga practitioners and individuals with metabolic syndrome

BACKGROUND

Stress places a metabolic burden on homeostasis and is linked to heightened sympathetic activity, increased energy expenditure and pathology. The yogic state is a hypometabolic state that corresponds with mind-body coherence and reduced stress. This study aimed to investigate metabolic responses to stress and different yoga practices in regular yoga practitioners (YP), non-yoga practitioners (NY) and metabolic syndrome patients (MS).

METHODS

YP (n = 16), NY (n = 15) and MS (n = 15) subjects underwent an experimental protocol that comprised of different 5-minute interventions including mental arithmetic stress test (MAST), alternate nostril breathing (ANB), Kapabhati breathing (KB) and meditation (Med) interspersed with 5 minutes of quiet resting (neutral condition (NC)). During the intervention periods continuous body weight adjusted oxygen consumption (VO2ml/min/kg) was measured using open circuit indirect calorimetry with a canopy hood.

RESULTS

This is the first study to report oxygen consumption (OC) in yoga practitioners during and after MAST and the first to report both within and between different populations. The results were analysed with SPSS 16 using 3X9 mixed factorial ANOVAs. The single between-subject factor was group (YP, NY and MS), the single within-subject factor was made up of the nine intervention phases (NC1, MAST, NC2, ANB, NC3, KB, NC4, Med, NC5). The results demonstrated that the regular YP group had significantly less OC and greater variability in their OC across all phases compared to the MS group (p = .003) and NY group (p = .01). All groups significantly raised their OC during the mental arithmetic stress, however the MS group had a significantly blunted post-stress recovery whereas the YP group rapidly recovered back to baseline levels with post stress recovery being greater than either the NY group or MS group.

CONCLUSIONS

Yoga practitioners have greater metabolic variability compared to non-yoga practitioners and metabolic syndrome patients with reduced oxygen requirements during resting conditions and more rapid post-stress recovery. OC in metabolic syndrome patients displays significantly blunted post-stress recovery demonstrating reduced metabolic resilience. Our results support the findings of previous randomised trials that suggest regular yoga practice may mitigate against the effects of metabolic syndrome.

CLINICAL TRIAL NUMBER

ACTRN12614001075673; Date of Registration: 07/10/2014.

Yoga for improving sleep quality and quality of life for older adults

CONTEXT

The aging process is associated with physiological changes that affect sleep. In older adults, undiagnosed and untreated insomnia may cause impaired daily function and reduced quality of life (QoL). Insomnia is also a risk factor for accidents and falls that are the main cause of accidental deaths in older adults and, therefore, is associated with higher morbidity and mortality rates in older populations.

OBJECTIVES

The research team aimed to (1) examine the efficacy of a yoga intervention (YI) for the treatment of insomnia in older adults, (2) determine the ability of yoga to enhance the QoL of older adults, and (3) establish the applicability of yoga practice for older people in a Western cultural setting.

DESIGN

A waiting-list controlled trial. Settings • The study took place in Jerusalem, Israel, from 2008-2009.

PARTICIPANTS

Participants were older men and women (age ≥ 60 y) with insomnia.

INTERVENTION

The YI group participated in 12 wk of classes, held 2 ×/wk, incorporating yoga postures, meditative yoga, and daily home practice of meditative yoga.

OUTCOME MEASURES

The study used self-report assessments of sleep quality using the following: (1) sleep quality-the Karolinska Sleepiness Scale (KSS), the Epworth Sleepiness Scale (ESS), and the Pittsburgh Sleep Quality Index (PSQI), and daily sleep and practice logs; (2) mood states-the Depression Anxiety Stress Scale long form (DASS-42) and the Profile of Mood States short form (POMS-SF); (3) a health survey (SF-36); and (4) mobile at-home sleep studies.

RESULTS

Compared with controls, the YI group showed significant improvements in a range of subjective factors, including overall sleep quality; sleep efficiency; sleep latency and duration; self-assessed sleep quality; fatigue; general well-being; depression; anxiety; stress; tension; anger; vitality; and function in physical, emotional, and social roles.

CONCLUSIONS

Yoga was shown to be safe and improved sleep and QoL in a group of older adults with insomnia. Outcomes depended on practice compliance.

A tailored, supportive care intervention using systematic assessment designed for people with inoperable lung cancer: a randomised controlled trial

OBJECTIVE

People with inoperable lung cancer experience higher levels of distress, more unmet needs and symptoms than other cancer patients. There is an urgent need to test innovative approaches to improve psychosocial and symptom outcomes in this group. This study tested the hypothesis that a tailored, multidisciplinary supportive care programme based on systematic needs assessment would reduce perceived unmet needs and distress and improve quality of life.

METHODS

A randomised controlled trial design was used. The tailored intervention comprised two sessions at treatment commencement and completion. Sessions included a self-completed needs assessment, active listening, self-care education and communication of unmet psychosocial and symptom needs to the multidisciplinary team for management and referral. Outcomes were assessed with the Needs Assessment for Advanced Lung Cancer Patients, Hospital Anxiety and Depression Scale, Distress Thermometer and European Organization of Research and Treatment of Cancer Quality of Life Q-C30 V2.0.

RESULTS

One hundred and eight patients with a diagnosis of inoperable lung or pleural cancer (including mesothelioma) were recruited from a specialist facility before the trial closed prematurely (original target 200). None of the primary contrasts of interest were significant (all p > 0.10), although change score analysis indicated a relative benefit from the intervention for unmet symptom needs at 8 and 12 weeks post-assessment (effect size = 0.55 and 0.40, respectively).

CONCLUSION

Although a novel approach, the hypothesis that the intervention would benefit perceived unmet needs, psychological morbidity, distress and health-related quality of life was not supported overall.

Primary Goals for Weight Loss Questionnaire (PGWLQ): Development and Psychometric Evaluation in Overweight and Obese Adults

Cognitive behavioural models suggest that individuals abandon their weight loss efforts because they fail to achieve their weight loss goal, their perceived benefits of weight loss (primary goals), or both. There are currently no published tools available to adequately measure primary goals. The purpose of the current study was to explore the factor structure and to evaluate the psychometric properties of the Primary Goals for Weight Loss Questionnaire (PGWLQ). One hundred and twenty-seven overweight and obese adult females actively trying to lose weight completed the PGWLQ. A four-factor solution (Comfort & Mobility; Fitness; Health & Illness; Participation & Activity) provided the best fit for the physical items, and a five-factor solution (Body Image & Self-esteem; Clothing Options & Fashion; Work Productivity & Opportunity; Social Life & Desirability; Sexual Confidence) provided the best fit for the psychosocial items. All PGWLQ factors demonstrated good convergent and discriminant validity. The PGWLQ demonstrated excellent internal consistency and weak to moderate test–retest reliability. Results of the present study suggest that the PGWLQ may be a promising research and clinical tool and further refinement of the PGWLQ and investigation of its factor structure is warranted.

Evolutionary history of plant multisubunit RNA polymerases IV and V: subunit origins via genome-wide and segmental gene duplications, retrotransposition, and lineage-specific subfunctionalization

Eukaryotes have three multisubunit DNA-dependent RNA polymerases that are essential for viability, abbreviated as Pol I, Pol II, and Pol III. Remarkably, Arabidopsis thaliana and other higher plants contain two additional nuclear multisubunit RNA polymerases, Pol IV and Pol V. These plant-specific polymerases are not essential for viability but have nonredundant roles in RNA-mediated gene-silencing pathways. Proteomic analyses have revealed that Arabidopsis Pol IV and Pol V have a 12-subunit composition like Pol II. In fact, half of the subunits of Pols II, IV, and V are encoded by the same genes. The remaining Pol IV- or Pol V-specific subunit genes arose through duplication and subfunctionalization of ancestral Pol II subunit genes. These include the genes encoding the largest subunits unique to Pol IV or Pol V, the genes encoding the second- and the fourth-largest subunits that are used by both Pol IV and Pol V, the gene encoding the fifth-largest subunit unique to Pol V and the genes encoding the seventh-largest subunits that are unique to Pol IV and Pol V. On the basis of phylogenetic reconstructions, the gene duplication events giving rise to the first-, second-, fourth-, fifth-, and seventh-largest subunits of Pol IV and/or Pol V occurred independently. Interestingly, a cDNA-mediated duplication of the Pol II seventh-largest subunit gene via retro-tranposition was an early event in Pol IV evolution, preceded only by the duplications of the largest and second-largest subunit genes. Secondary duplication of this cDNA-like gene to generate Pol IV- and Pol V-specific seventh-largest subunits has occurred in Arabidopsis but not all dicotyledonous plants or monocots, indicative of the dynamic evolution of RNA Pol IV and Pol V in plants.

Energy expended by adults with and without intellectual disabilities during activities of daily living

The aims of this study were to (1) determine the energy expenditure of adults with and without intellectual disabilities during common activities of daily living (ADL), (2) use these values to evaluate the accuracy of equivalent activity values reported in the Compendium of Physical Activities (CPA), and (3) identify ADL that may confer a health benefit for adults with intellectual disabilities when undertaken regularly. Energy expenditure was measured for adults with intellectual disabilities (N=31; 29.0±8.6 yr) and adults without intellectual disabilities (N=15; 30.4±9.6 yr) while undertaking each of seven ADL: sitting quietly (SitQ); sitting watching television (SitTV); sitting and standing while completing an assembly task (SitAT, StaAT); and walking at a slow (WalkS, 3.0 km h(-1)), quick (WalkQ, 6.0 km h(-1)) and fast (WalkF, 9.0 km h(-1)) speed, under laboratory conditions. Adults with intellectual disabilities were found to expend significantly more energy than adults without intellectual disabilities for SitQ, WalkS, WalkQ and WalkF (p<0.05). Energy expended by both populations was significantly more than CPA values for SitQ, SitTV, SitAT, WalkS, and WalkQ (p<0.02) and significantly less for WalkF (p<0.01). Walking at the speed of 3.0 km h(-1) (50 m min(-1)) was found to be sufficient to achieve moderate-intensity energy expenditure, surpassing the intensity threshold for conferring a health benefit. Energy expenditure inaccuracies of the CPA have important consequences when estimating prevalence of engagement in health enhancing physical activities among population sub-groups. The identification of slow walking as a moderate-intensity physical activity offers significant health promotion opportunities for adults with intellectual disabilities through active transport and leisure.

Observing the behaviour and interactions of adults with congenital deafblindness living in community residences

BACKGROUND

Adults with congenital deafblindness (CDB) have received little attention from researchers. In this study we examined the nature of interactions between adults with CDB and the staff who mediate their support, and investigated the reliability of an observation coding system, originally designed for observing adults with severe intellectual disability.

METHOD

The behaviours of 9 adults with CDB, including their interactions with support staff from 2 community residences, were recorded and subsequently coded by 2 observers.

RESULTS

Interrater reliability, measured using Cohen's k, was variable across the coding system. Adults with CDB were predominantly observed to be disengaged, with few observations of engagement according to the coding schedule's definition of engagement. Interactions between the residents and support staff were rare.

CONCLUSION

The introduction of interventions designed for staff to promote resident engagement in social interaction is recommended.

Effects of child characteristics on the outcomes of a parent support program

BACKGROUND

Previous research has reported on the effectiveness of the Signposts program for supporting families of children with an intellectual disability and difficult behaviour (Hudson et al., 2003; Hudson, Cameron, & Matthews, 2008). This paper reports on an investigation of the extent to which child characteristics moderate the effectiveness of the program.

METHOD

Data collected from 689 participants in the Signposts program were analysed to examine if the child characteristics of gender, age, or associated disability impacted on outcomes.

RESULTS

The gender analyses produced mean effect sizes of 0.39 for boys and 0.42 for girls; however, this difference was not statistically significant. The age analyses produced mean effect sizes of 0.38 for children aged 2-5 years, 0.42 for children aged 6-12 years, and 0.30 for children aged 13-18 years; however, these differences among the age groups were not statistically significant. The associated disability analyses across 7 groups produced mean effect sizes ranging from 0.31 to 0.75; however, the differences among these groups were not statistically significant.

CONCLUSIONS

First, gender was not a moderating variable. Second, while the effect size for the older age group seemed to be marginally lower than that of the other two groups, age was not found to be a moderating variable. Finally, type of associated disability was not found to be a moderating variable. Methodological limitations of the study necessitate care in interpreting the findings.

Cognitive-behavioral therapy versus temporal pulse amplitude biofeedback training for recurrent headache

Sixty-four headache sufferers were allocated randomly to cognitive-behavioral therapy (CBT), temporal pulse amplitude (TPA) biofeedback training, or waiting-list control. Fifty-one participants (14M/37F) completed the study, 30 with migraine and 21 with tension-type headache. Treatment consisted of 8, 1-hour sessions. CBT was highly effective, with an average reduction in headaches from pre- to posttreatment of 68%, compared with 56% for biofeedback, and 20% for the control condition. Headaches continued to decrease to 12 month follow-up for CBT. Improvement with CBT was associated with baseline coping skills, social support, and physiological measures at rest and in response to stress, particularly TPA. Changes on some of these measures were correlated with changes in headaches. No significant predictors of response to biofeedback emerged.

Effects of body position on autonomic regulation of cardiovascular function in young, healthy adults

Background

Analysis of rhythmic patterns embedded within beat-to-beat variations in heart rate (heart rate variability) is a tool used to assess the balance of cardiac autonomic nervous activity and may be predictive for prognosis of some medical conditions, such as myocardial infarction. It has also been used to evaluate the impact of manipulative therapeutics and body position on autonomic regulation of the cardiovascular system. However, few have compared cardiac autonomic activity in supine and prone positions, postures commonly assumed by patients in manual therapy. We intend to redress this deficiency.

Methods

Heart rate, heart rate variability, and beat-to-beat blood pressure were measured in young, healthy non-smokers, during prone, supine, and sitting postures and with breathing paced at 0.25 Hz. Data were recorded for 5 minutes in each posture: Day 1 – prone and supine; Day 2 – prone and sitting. Paired t-tests or Wilcoxon signed-rank tests were used to evaluate posture-related differences in blood pressure, heart rate, and heart rate variability.

Results

Prone versus supine: blood pressure and heart rate were significantly higher in the prone posture (p < 0.001). Prone versus sitting: blood pressure was higher and heart rate was lower in the prone posture (p < 0.05) and significant differences were found in some components of heart rate variability.

Conclusion

Cardiac autonomic activity was not measurably different in prone and supine postures, but heart rate and blood pressure were. Although heart rate variability parameters indicated sympathetic dominance during sitting (supporting work of others), blood pressure was higher in the prone posture. These differences should be considered when autonomic regulation of cardiovascular function is studied in different postures.

Noise as a Trigger for Headaches: Relationship Between Exposure and Sensitivity

OBJECTIVE

This study investigated how triggers acquire the capacity to precipitate headaches.

BACKGROUND

Traditional clinical advice is that the best way to prevent headache/migraine is to avoid the triggers. Avoidance of anxiety-eliciting stimuli, however, results in sensitization to the stimuli, so is there a danger that avoidance of migraine/headache triggers results in decreased tolerance for the triggers?

DESIGN

One hundred and fifty subjects, 60 of whom suffered from regular headaches, were randomly assigned to 5 experimental conditions, defined by length of exposure to the headache trigger of noise.

METHODS

Subjects attended a laboratory session divided into 3 phases: preintervention test, intervention (1 of 5 levels of exposure to the trigger), and postintervention test. Response to the intervention was measured in terms of noise tolerance, sensitivity to noise, and nociceptive response to noise.

RESULTS

A curvilinear relationship was found between length of exposure to the trigger and pain response for individuals who do not suffer from regular headaches, that is, short exposure was associated with sensitization and prolonged exposure with desensitization. The relationship for headache patients was less clear.

CONCLUSIONS

The findings are consistent with the proposition that 1 etiological pathway to suffering from frequent headaches is via trying to avoid, or escape from, potential trigger factors. These results suggest that the traditional clinical advice to headache patients, that the best way to prevent migraine/headache is to avoid the triggers, runs the risk of establishing an insidious sensitization process thereby increasing headache frequency.

Effects of Noise and a Stressor on Head Pain

OBJECTIVE

Can causal relationships be established between negative affect (NA) and headaches, and noise (N) and headaches? Do NA and N interact to cause headaches? Do NA and N cause headaches by means of the same or different physiological mechanisms? Are the answers to these questions a function of diagnostic status?

BACKGROUND

A functional model of chronic headaches has been proposed that seeks to understand the variance in headaches by focusing on the controlling variables, that is, the antecedents and consequences. This study is one in a series investigating the immediate antecedents of headaches, namely the trigger factors.

DESIGN

Twenty-four subjects with migraine and 44 subjects with tension-type headache were randomly assigned to one of four experimental conditions defined by the presence or absence of two antecedent challenges, a stressor (S) designed to induce NA and N.

METHODS

The S challenge consisted of difficult-to-solve anagrams accompanied by failure feedback. The N challenge consisted of 50 dB of white N. Laboratory sessions were divided into adaptation, baseline, challenge, and recovery phases. Responses were measured in terms of headache intensity ratings, forehead electromyographic activity, heart rate, blood pressure, and temporal pulse amplitude (TPA).

RESULTS AND CONCLUSIONS

Both NA and N precipitated headaches. These two factors did not interact in triggering headaches. Headaches induced by N were associated with elevated TPA but headaches induced by NA were not associated with significant physiological changes. Diagnosis was not related to any of the outcomes.

"It's as if you're locked in": qualitative explanations for area effects on smoking in disadvantaged communities

Evidence suggests that place of residence may be associated with smoking independently of individual poverty and socio-economic status. Qualitative research undertaken in disadvantaged communities in Glasgow explored possible pathways which might explain this 'area effect'. A poorly resourced and stressful environment, strong community norms, isolation from wider social norms, and limited opportunities for respite and recreation appear to combine not only to foster smoking but also to discourage or undermine cessation. Even the more positive aspects of life, such as support networks and identity, seem to encourage rather than challenge smoking. Policy and intervention responses need to tackle not only individual but also environmental disadvantage.

Evaluation of amylase and lipase in the diagnosis of acute pancreatitis

BACKGROUND

The diagnosis of acute pancreatitis relies heavily on a raised amylase.

METHODS

In the present study patients were prospectively categorized, without knowledge of pancreatic enzyme levels, into acute pancreatitis (AP; n = 51), disease controls (n = 35), indeterminate as to pancreatitis (n = 189) or exclusions (non-pancreatitis diseases where amylase may be elevated; n = 53).

RESULTS

Enzyme levels were analysed by receiver operator characteristics (ROC) curves, with specificity > 80%. Day 1 serum lipase gave the greatest diagnostic accuracy (area under ROC curve = 0.128; P = 0.041 vs serum amylase). At the calculated diagnostic threshold of 208 U/L, lipase gave a sensitivity of 67% and a specificity of 97%. Other diagnostic thresholds (day 1) were: serum total amylase, 176 U/L (ROC 0.104, sensitivity 45%, specificity 97%), urinary total amylase, 550 U/L (ROC 0.108, sensitivity 62%, specificity 97%) and serum pancreatic isoamylase, 41 U/L (ROC 0.107, sensitivity 63%, specificity 85%). At delayed diagnosis (3 days) no enzyme was superior to lipase. The combination of lipase and amylase did not increase diagnostic accuracy.

CONCLUSION

Serum lipase is recommended for diagnosis of AP, both early and late in the disease. Although highly specific when elevated, all pancreatic enzymes have low sensitivity for diagnosis.

The 1998 Lindberg Award. Comparison of glycerol preservation with cryopreservation methods on HIV-1 inactivation

Cryopreservation and glycerol preservation are 2 successful methods for long-term preservation of human cadaver skin. Preservation is subjected to strict criteria to minimize the risk of disease transmission. This investigation compares the effects of glycerol preservation and cryopreservation on the inactivation of HIV-1. The effects of glycerol preservation and cryopreservation on inactivation of both extracellular and intracellular HIV-1Ba-L were investigated. After exposing HIV-1Ba-L-infected material to various concentrations of glycerol or to 10% dimethyl sulfoxide followed by cryopreservation, uninfected peripheral blood mononuclear cells were added to the treated material. At different time points during the culture, supernatants were taken to quantify HIV-1Ba-L and reverse transcriptase levels to determine HIV-1Ba-L infectivity. Cell-free HIV-1Ba-L was inactivated within 30 minutes in 70% and 85% glycerol. Also, intracellular HIV-1Ba-L in infected peripheral blood mononuclear cells or infected cadaver skin was completely inactivated by glycerol treatment in vitro. Cryopreservation did not show any extracellular or intracellular HIV-1Ba-L inactivation. Glycerol preservation--but not cryopreservation--of human cadaveric donor skin can inactivate both extracellular and intracellular HIV-1.

Female survivors of abuse attending A & E with self-injury

Accident and Emergency departments are concerned with trauma whatever the source or client age. This mixed trauma culture can be a distressing place, not least for women whose self-injury is 'self-inflicted' rather than accidental in nature. The women, who might be survivors of childhood sexual abuse, are sometimes viewed as service abusers, on occasions subjected to misinterpretation, labelled as 'time-wasters' and consequently stigmatized. The misunderstanding based on misinterpretation of language and theory is explored briefly, as is some appropriate literature on self-injury and abuse. The definitions of self-injury and some of the myths associated with self-injuring women are developed. The relationship of self-injury with suicide is briefly explored, as are issues related to distress and self-injury. The demand on nurses and the case for the development of an appropriate non-medical theory is explored. Areas of positive practice, some of which were visited while the author was on a Nightingale Scholarship, are noted as is the need for nurses to learn from voluntary and survivor groups who work with and for self-injuring women. Client needs and staff awareness is examined in brief. Literature from the survivor perspective is utilized and the conclusion is drawn largely from the recommendations made by this literature.