Category: Mental Health Treatment

The Challenges of a Pandemic in Secure Psychiatric Settings

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“Before COV-19, the phrase “parity of esteem” was ubiquitous.

Policy makers and politicians emphasised the importance of high quality mental healthcare, insisting it was on an equal footing with physical healthcare.

Most mental health professionals viewed this with some cynicism, especially those working in secure inpatient settings.

Is it reasonable to expect parity when it comes to covid-19? Arguably it would not be reasonable to expect the same focus on, for example, PPE and testing as that directed towards the acute emergency services and intensive care.

However, inpatient units struggled with the lack of central guidance on managing patients who had been diagnosed with or were suspected of having covid-19.

Patients with serious mental disorders are at high risk of physical health problems. While they are acutely unwell, they:

  • May not have the capacity to understand the need to self-isolate;
  • May be unable or unwilling to be tested; and
  • If agitated, will be unlikely to be able to practice social distancing.

Mental health trusts have been struggling:

  • With protocols and the availability of testing;
  • With managing the direct contacts of patients; and
  • Like other settings, with sourcing appropriate PPE.

There is intense debate about the apparent lack of appropriate legal frameworks. In the case of a voluntary or inform patient, can the Mental Health Act be used? The Mental Capacity Act is not appropriate as it applies top decisions in the patient’s best interests, not for the protection of others.

The Coronavirus Act 2020 give public health officers the power to impose isolation on someone suspected of being infected, but this seems unlikely to extend to inpatient units.

If parity of esteem is ever going to be meaningful, the challenges of safely and securely managing coivd-19 in the most seriously unwell patients with mental disorders needs to be given a higher priority.”

Reference

O’Brien, A. (2020) The Challenges of a Pandemic in Secure Psychiatric Settings. BMJ 2020;369:No.8247, pp.318-319.

Can Internet-Based CBT be used to Treat Young People with OCD?

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Research Paper Title

Online Obsessive-Compulsive Disorder Treatment: Preliminary Results of the “OCD? Not Me!” Self-Guided Internet-Based Cognitive Behavioral Therapy Program for Young People.

Background

The development and evaluation of Internet-delivered cognitive behavioral therapy (iCBT) interventions provides a potential solution for current limitations in the acceptability, availability, and accessibility of mental health care for young people with obsessive-compulsive disorder (OCD).

Preliminary results support the effectiveness of therapist-assisted iCBT for young people with OCD; however, no previous studies have examined the effectiveness of completely self-guided iCBT for OCD in young people.

The researches aimed to conduct a preliminary evaluation of the effectiveness of the OCD? Not Me! program for reducing OCD-related psychopathology in young people (12-18 years). This programme is an eight-stage, completely self-guided iCBT treatment for OCD, which is based on exposure and response prevention.

Methods

These data were early and preliminary results of a longer study in which an open trial design is being used to evaluate the effectiveness of the OCD? Not Me!

Participants were required to have at least subc-linical levels of OCD to be offered the online program. Participants with moderate-high suicide/self-harm risk or symptoms of eating disorder or psychosis were not offered the programme. OCD symptoms and severity were measured at pre- and post-test, and at the beginning of each stage of the programme. Data was analysed using generalised linear mixed models.

Results

A total of 334 people were screened for inclusion in the study, with 132 participants aged 12 to 18 years providing data for the final analysis.

Participants showed significant reductions in OCD symptoms (P<.001) and severity (P<.001) between pre- and post-test.

Conclusions

These preliminary results suggest that fully automated iCBT holds promise as a way of increasing access to treatment for young people with OCD; however, further research needs to be conducted to replicate the results and to determine the feasibility of the programme.

Reference

Rees, C.S., Anderson, R.A., Kane, R.T. & Finaly-Jones, A.L. (2016) Online Obsessive-Compulsive Disorder Treatment: Preliminary Results of the “OCD? Not Me!” Self-Guided Internet-Based Cognitive Behavioral Therapy Program for Young People. JMIR Mental Health. 3(3):e29. doi: 10.2196/mental.5363.

Is ERRT-M Useful and Credible?

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Research Paper Title

A Pilot Randomized Controlled Trial of Cognitive Behavioral Treatment for Trauma-Related Nightmares in Active Duty Military Personnel.

Background

The aim of this study was to obtain preliminary data on the efficacy, credibility, and acceptability of Exposure, relaxation, and rescripting therapy for military service members and veterans (ERRT-M) in active duty military personnel with trauma-related nightmares.

Methods

Forty participants were randomised to either 5 sessions of ERRT-M or 5 weeks of minimal contact control (MCC) followed by ERRT-M. Assessments were completed at baseline, post-treatment/post-control, and 1-month follow-up.

Results

Differences between ERRT-M and control were generally medium in size for nightmare frequency (Cohen d = -0.53), nights with nightmares (d = -0.38), nightmare severity (d = -0.60), fear of sleep (d = -0.44), and symptoms of insomnia (d = -0.52), and depression (d = -0.51).

In the 38 participants who received ERRT-M, there were statistically significant, medium-sized decreases in nightmare frequency (d = -0.52), nights with nightmares (d = -0.50), nightmare severity (d = -0.55), fear of sleep (d = -0.48), and symptoms of insomnia (d = -0.59), post-traumatic stress disorder (PTSD) (d = -0.58) and depression (d = -0.59) from baseline to 1-month follow-up.

Participants generally endorsed medium to high ratings of treatment credibility and expectancy.

The treatment dropout rate (17.5%) was comparable to rates observed for similar treatments in civilians.

Conclusions

ERRT-M produced medium effect-size reductions in nightmares and several secondary outcomes including PTSD, depression, and insomnia.

Participants considered ERRT-M to be credible.

An adequately powered randomised clinical trial is needed to confirm findings and to compare ERRT-M to an active treatment control.

Reference

Pruiksma, K.E., Taylor, D.J., Mintz, J., Nicholson, K.L., Rodgers, M., Young-McCaughan, S., Hall-Clark, B.N., Fina, B.A., Dondanville, K.A., Cobos, B., Wardle-Pinkston, S., Litz, B.T., Roache, J.D., Perterson, A.L. & STRONG STAR Consortium. (2020) A Pilot Randomized Controlled Trial of Cognitive Behavioral Treatment for Trauma-Related Nightmares in Active Duty Military Personnel. Journal of Clinical Sleep Medicine. 16(1), pp.29-40. doi: 10.5664/jcsm.8116. Epub 2019 Nov 26.

Can a Novel Algorithmic Approach Operationalise the Management of Depression & Anxiety for Primary Care?

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Research Paper Title

Effects of Brief Depression and Anxiety Management Training on a US Army Division’s Primary Care Providers.

Background

There is a nation-wide gap between the prevalence of mental illness and the availability of psychiatrists. This places reliance on primary care providers (PCPs) to help meet some of these mental health needs.

Similarly, the US Army expects its PCPs to be able to manage common mental illnesses such as anxiety and depression. Therefore, PCPs must be able to close their psychiatric skills gaps via lifelong learning.

Methods

Following needs assessment of PCPs in a US Army division, the curriculum was developed. Objectives targeted pharmacological management of depression and anxiety. Behavioural intervention skills were also taught to treat insomnia.

Didactics and case-based small groups were used. A novel psychotropic decisional tool was developed and provided to learners to assist and influence their future psychiatric practice. Pre-training, immediate post-training, and 6-month assessments were done via survey to evaluate confidence and perceived changes in practice.

The curriculum was executed as a quality improvement project using the Plan, Do, Study, Act framework.

Results

Among 35 learners, immediate confidence in selecting optimal psychotropic and perceived knowledge, skill to change the dose or type of medication, and confidence in prescribing behavioural sleep improved significantly with large effect sizes.

At 6-month follow-up, learners reported that they were more likely to adjust medications for anxiety or depression and were more likely to start a new medication for anxiety or depression because of the training with moderate effect sizes. Use and satisfaction with the psychotropic decisional tool are also reported.

Conclusions

The psychotropic decisional tool illustrates a novel algorithmic approach for operationalising the management of depression and anxiety.

Similar approaches can improve the skills of a variety of PCPs in the management of psychiatric disorders.

Further studies in the military operational setting are needed to assess the effects of similar educational interventions on access to behavioural health care, suicidal behaviours, and unit medical readiness.

Reference

Amin, R. & Thomas, M.A. (2020) Effects of Brief Depression and Anxiety Management Training on a US Army Division’s Primary Care Providers. Military Medicine. doi: 10.1093/milmed/usz443. Online ahead of print.

Substance Use & Intervention Programmes: Remember to Address Social Issues Regardless of Deployment History

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Research Paper Title

Problems With Social Acceptance and Social Victimization Predict Substance Use Among U.S. Reserve/Guard Soldiers.

Background

The effects of negative social interactions/experiences on substance use have largely been studied in civilian populations, but less is known about United States Army Reserve/National Guard (USAR/NG) soldiers-a high-risk group.

Methods

The researchers examined the associations between problems with social acceptance, social victimisation, and substance use among USAR/NG soldiers, and examined potential differences by deployment history.

The sample consisted of soldiers who completed baseline and 1-year follow-up assessments (N = 445) of Operation: SAFETY, an ongoing study of USAR/NG soldiers.

They examined the effects of baseline problems with social acceptance/social victimization on nonmedical use of prescription drugs (NMUPD), illicit drug use, frequent heavy drinking (FHD), and alcohol problems at follow-up.

Results

Significant effects were small in magnitude but consistent in direction.

Greater problems with social acceptance were associated with higher odds of NMUPD and illicit drug use.

Greater social victimisation was associated with higher odds of NMUPD and illicit drug use.

There were no differences by deployment history.

Conclusions

Problems with social acceptance/social victimisation were not associated with FHD or alcohol problems.

Problems with social acceptance/social victimisation may contribute to drug use among USAR/NG soldiers.

Intervention programmes should address social issues, regardless of deployment history.

Reference

Hoopsick, R.A., Vest, B.M., Homish, D.L. & Homish, G.G. (2020) Problems With Social Acceptance and Social Victimization Predict Substance Use Among U.S. Reserve/Guard Soldiers. Stress and Health. doi: 10.1002/smi.2934. Online ahead of print.

Components & Principles of Effective Treatments in Mental Health

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For interventions (to at least be perceived) to be effective in the treatment of mental health conditions, from the perspective of the service user, there are a range of components that one must understand and appreciate.

  • Facilitative service environment(s):
    • Understand how the environment can affect a service user’s experience of treatment.
    • Prioritise good relationships between staff/volunteers and those using the services.
    • Taking a genuine interest in the service user.
    • Being respectful.
    • Helps service users feel at ease and prevent relapse.
  • Access to appropriate treatment(s).
  • Compassionate and non-judgemental support.
    • This can include peer, practical, and emotional support.
  • Interventions that are long enough in duration:
    • Treatment needs to be long enough in duration for the service user to avoid relapse and/or move into recovery.
    • Need for ongoing support.
    • Aftercare programme as a way of ensuring a supportive network to prevent relapse.
  • Interventions that offer stability.
  • Choices (in terms of treatment).
    • Service users like to feel they have a choice in their treatment.
    • Want to be treated as individuals.
    • Individualised care means provider must have flexibility in service delivery.
  • Opportunities to learn (or relearn) how to live.
    • Treatment should be seen as providing opportunities for service users to learn (vocational/life) skills to support them to live their lives.
    • This can aid service users to steer away from problematic patterns of behaviour by providing structure and purpose, alleviating boredom, and distraction from their condition.

The above should be provided with the following three principles in mind:

  1. Within the context of good relationships.
    • You are not there to be the service user’s best friend, but good/positive relationships aid effectiveness of treatment and perceptions of service.
  2. Person-centred care.
    • Where appropriate and practicable, the service/treatment should fit around the service user, not the service user around the service/treatment.
  3. Understanding the complexity of the service user’s (both personal and professional) circumstances.
    • Understanding of the service user’s circumstances can aid adherence to treatment and their journey through their condition.

Finally, remember that the way in which services and treatment are delivered, is considered by many service users, to be more important than the type of treatment provided.

Homelessness & Substance Use Treatment: Is the Way in which Services & Treatment are Delivered more Important than the Type of Treatment Provided?

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Research Paper Title

What Constitutes Effective Problematic Substance Use Treatment From the Perspective of People Who Are Homeless? A Systematic Review and Meta-Ethnography.

Background

People experiencing homelessness have higher rates of problematic substance use but difficulty engaging with treatment services. There is limited evidence regarding how problematic substance use treatment should be delivered for these individuals.

Previous qualitative research has explored perceptions of effective treatment by people who are homeless, but these individual studies need to be synthesised to generate further practice-relevant insights from the perspective of this group.

Methods

Meta-ethnography was conducted to synthesise research reporting views on substance use treatment by people experiencing homelessness. Studies were identified through systematic searching of electronic databases (CINAHL; Criminal Justice Abstracts; Health Source; MEDLINE; PsycINFO; SocINDEX; Scopus; and Web of Science) and websites and were quality appraised. Original participant quotes and author interpretations were extracted and coded thematically.

Concepts identified were compared to determine similarities and differences between studies. Findings were translated (reciprocally and refutationally) across studies, enabling development of an original over-arching line-of-argument and conceptual model.

Results

Twenty-three papers published since 2002 in three countries, involving 462 participants, were synthesised. Findings broadly related, through personal descriptions of, and views on, the particular intervention components considered effective to people experiencing homelessness. Participants of all types of interventions had a preference for harm reduction-oriented services.

Participants considered treatment effective when it provided a facilitative service environment; compassionate and non-judgemental support; time; choices; and opportunities to (re)learn how to live. Interventions that were of longer duration and offered stability to service users were valued, especially by women.

From the line-of-argument synthesis, a new model was developed highlighting critical components of effective substance use treatment from the service user’s perspective, including a service context of good relationships, with person-centred care and an understanding of the complexity of people’s lives.

Conclusions

This is the first meta-ethnography to examine the components of effective problematic substance use treatment from the perspective of those experiencing homelessness. Critical components of effective problematic substance use treatment are highlighted.

The way in which services and treatment are delivered is more important than the type of treatment provided. Substance use interventions should address these components, including prioritising good relationships between staff and those using services, person-centred approaches, and a genuine understanding of individuals’ complex lives.

Reference

Carver, H., Ring, N., Miler, J. & Parkes, T. (2020) What Constitutes Effective Problematic Substance Use Treatment From the Perspective of People Who Are Homeless? A Systematic Review and Meta-Ethnography. Harm Reduction Journal. 17(1), pp.10. doi: 10.1186/s12954-020-0356-9.

Can Acupressure Reduce Soldiers’ Anxiety in Stressful Situations?

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Research Paper Title

Effects of Acupressure at the P6 and LI4 Points on the Anxiety Level of Soldiers in the Iranian Military.

Background

Military service is a stressful environment. Methods to reduce stress may result in the mental health promotion of military forces.

There are various methods for relieving anxiety. Acupressure is one of them.

Hence, this study was carried out to explore effects of acupressure at the P6 and LI4 acupressure points on the anxiety level of army soldiers.

Methods

A randomised double-blind design was undertaken. A total of 120 Iranian army soldiers were randomly assigned to three groups, namely P6, LI4 and control. The P6 and LI4 acupressure points are effective in lowering the anxiety level.

In the intervention groups, acupressure was applied at the P6 and LI4 points three times for 10 min at 30 min intervals. In the control group, the thumb pad, which is not an acupressure point, was pressed.

The anxiety level of the subjects was measured before the intervention and 30 min after the last intervention. The instruments included a demographics questionnaire and the State-Trait Anxiety Inventory.

Results

There was no significant difference between the three groups with respect to the anxiety level in the preintervention phase. However, the mean anxiety score in the P6 group decreased significantly from 53.35±9.7 to 49.02±9.3 (p=0.005).

The mean anxiety score in the LI4 group also decreased significantly from 53.37±8.39 to 45.47±8.16 (p<0.001).

In the control group, there was no significant difference between the preintervention and postintervention phases (p=0.16).

In the postintervention phase, the analysis of variance test showed a significant difference between the three groups in terms of the anxiety level (p=0.04).

Conclusions

Acupressure can reduce soldiers’ anxiety at the acupressure points, especially at the LI4 point.

It is recommended that this simple and cost-effective intervention be used to relieve soldiers’ anxiety in stressful situations.

Reference

Rarani, S.A., Rajai, N. & Sharififar, S. (2020) Effects of Acupressure at the P6 and LI4 Points on the Anxiety Level of Soldiers in the Iranian Military. BMJ Military Health. doi: 10.1136/jramc-2019-001332. Online ahead of print.

Should We Target Inflammation, The Gut Microbiome, and Mitochondrial Dysfunction in Combat PTSD-Metabolism?

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Research Paper Title

Novel Pharmacological Targets for Combat PTSD-Metabolism, Inflammation, The Gut Microbiome, and Mitochondrial Dysfunction

Background

Current pharmacological treatments of post-traumatic stress disorder (PTSD) have limited efficacy.

Although the diagnosis is based on psychopathological criteria, it is frequently accompanied by somatic comorbidities and perhaps “accelerated biological ageing,” suggesting widespread physical concomitants.

Such physiological comorbidities may affect core PTSD symptoms but are rarely the focus of therapeutic trials.

Methods

To elucidate the potential involvement of metabolism, inflammation, and mitochondrial function in PTSD, the researchers integrate findings and mechanistic models from the DOD-sponsored “Systems Biology of PTSD Study” with previous data on these topics.

Results

Data implicate inter-linked dysregulations in metabolism, inflammation, mitochondrial function, and perhaps the gut microbiome in PTSD.

Several inadequately tested targets of pharmacological intervention are proposed, including insulin sensitisers, lipid regulators, anti-inflammatories, and mitochondrial biogenesis modulators.

Conclusions

Systemic pathologies that are intricately involved in brain functioning and behaviour may not only contribute to somatic comorbidities in PTSD, but may represent novel targets for treating core psychiatric symptoms.

Reference

Bersani, F.S., Mellon, S.H., Lindqvist, D., Kang, J.I., Rampersaud, R., Somvanshi, P.R., Doyle, F.J., Hammamieh, R., Jett, M., Yehuda, R., Marmar, C.R. & Wolkowitz, O.M. (2020) Novel Pharmacological Targets for Combat PTSD-Metabolism, Inflammation, The Gut Microbiome, and Mitochondrial Dysfunction

Evidence-Based Practices for the (Web-based) Treatment of PTSD

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Research Paper Title

Understanding How Clinicians Use a New Web-based Tool for Disseminating Evidence-Based Practices for the Treatment of PTSD: The PTSD Clinicians Exchange.

Background

Web-based interventions hold great promise for the dissemination of best practices to clinicians, and investment in these resources has grown exponentially. Yet, little research exists to understand their impact on intended objectives.

Methods

The Post-Traumatic Stress Disorder (PTSD) Clinicians Exchange is a website to support clinicians treating veterans and active duty military personnel with PTSD, evaluated in a randomised controlled trial (N = 605). This manuscript explores how a subset of clinicians, those who utilised the intervention (N = 148), engaged with it by examining detailed individual-level web analytics and qualitative feedback. Stanford University and New England Research Institutes Institutional Review Boards approved this study.

Results

Only 32.7% of clinicians randomised to the intervention ever accessed the website. The number of pages viewed was positively associated with changes from baseline to 12 months in familiarity (P = 0.03) and perceived benefit of practices (P = 0.02). Thus, engagement with the website did predict an improvement in practice familiarity and benefit outcomes despite low rates of use.

Conclusions

This study demonstrates the importance of methodologically rigorous evaluations of participant engagement with web-based interventions.

These approaches provide insight into who accesses these tools, when, how, and with what results, which can be translated into their strategic design, evaluation, and dissemination.

Reference

Coleman, J.L., Marceau, L., Zincavage, R., Magnavita, A.M., Ambrosoli, J., Shi, L., Simon, E., Ortigo, K., Clarke-Walper, K., Penix, E., Wilk, J., Ruzek, J.I. & Rosen, R.C. (2020) Understanding How Clinicians Use a New Web-based Tool for Disseminating Evidence-Based Practices for the Treatment of PTSD: The PTSD Clinicians Exchange. Military Medicine. 185(Suppl 1), pp.286-295. doi: 10.1093/milmed/usz313.