Category: Mental Health Treatment

Education: Text-based Coaching Protocols for Digital Mental Health Interventions

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Research Paper Title

Guidance on defining the scope and development of text-based coaching protocols for digital mental health interventions.

Background

A body of literature suggests that the provision of human support improves both adherence to and clinical outcomes for digital mental health interventions.

While multiple models of providing human support, or coaching, to support digital mental health interventions have been introduced, specific guidance on how to develop coaching protocols has been lacking.

In this Education Piece, the authors provide guidance on developing coaching protocols for text-based communication in digital mental health interventions.

Researchers and practitioners who are tasked with developing coaching protocols are prompted to consider the scope of coaching for the intervention, the selection and training of coaches, specific coaching techniques, how to structure communication with clients and how to monitor adherence to guidelines, and quality of coaching.

Their goal is to advance thinking about the provision of human support in digital mental health interventions to inform stronger, more engaging, and effective intervention designs.

Reference

Lattie, E.G., Graham, A.K., Hadjistavropoulos, H.D., Dear, B.F., Titov, N. & Mohr, D.C. (2019) Guidance on defining the scope and development of text-based coaching protocols for digital mental health interventions. Digital Health. doi: 10.1177/2055207619896145. eCollection 2019 Jan-Dec.

Review of Physical Health Monitoring after Rapid Tranquilisation for Acute Behavioural Disturbance

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Research Paper Title

Physical health monitoring after rapid tranquillisation: clinical practice in UK mental health services.

Background

The researchers aimed to assess the quality of physical health monitoring following rapid tranquillisation (RT) for acute behavioural disturbance in UK mental health services.

Methods

The Prescribing Observatory for Mental Health (POMH-UK) initiated an audit-based quality improvement programme addressing the pharmacological treatment of acute behavioural disturbance in mental health services in the UK.

Results

Data relating to a total of 2454 episodes of RT were submitted by 66 mental health services.

Post-RT physical health monitoring did not reach the minimum recommended level in 1933 (79%) episodes.

Patients were more likely to be monitored (OR 1.78, 95% CI 1.39-2.29, p < 0.001) if there was actual or threatened self-harm, and less likely to be monitored if the episode occurred in the evening (OR 0.79, 95% CI 0.62-1.0, p < 0.001) or overnight (OR 0.57, 95% CI 0.44-0.75, p < 0.001).

Risk factors such as recent substance use, RT resulting in the patient falling asleep, or receiving high-dose antipsychotic medication on the day of the episode, did not predict whether or not the minimum recommended level of post-RT monitoring was documented.

Conclusions

The minimum recommended level of physical health monitoring was reported for only one in five RT episodes.

The findings also suggest a lack of targeting of at-risk patients for post-RT monitoring.

Possible explanations are that clinicians consider such monitoring too demanding to implement in routine clinical practice or not appropriate in every clinical situation.

For example, physical health measures requiring direct contact with a patient may be difficult to undertake, or counter-productive, if RT has failed.

These findings prompt speculation that post-RT monitoring practice would be improved by the implementation of guidance that integrated and refined the currently separate systems for undertaking and recording physical health observations post-RT, determining nursing observation schedules and detecting acute deterioration in physical health.

The effectiveness and clinical utility of such an approach would be worth testing.

Reference

Paton, C., Adams, C.E., Dye, S., Delgado, O., Okocha, C. & Barnes, T.R.E. (2019) Physical health monitoring after rapid tranquillisation: clinical practice in UK mental health services. Therapeutic Advances in Psychopharmacology. doi: 10.1177/2045125319895839. eCollection 2019.

Treating Schizophrenic with Comorbid Alopecia Universalis (AU) with add-on High Definition Transcranial Direct Current Stimulation (HD-tDCS

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Research Paper Title

Successful application of add-on high-definition transcranial direct current stimulation in a schizophrenic patient with comorbid alopecia universalis.

Background

High-definition transcranial direct current stimulation (HD-tDCS), an advanced version of tDCS, is found to show alleviation of auditory verbal hallucinations (AVHs) as an add-on treatment modality in schizophrenia.

There is a scarcity of data evaluating the utility and tolerability of the same.

Local skin-related side effects are the most common adversities reported with HD-tDCS.

Density of hair follicles is hypothesised to be influencing the sensory adversities related to electrical stimulation and insulation, and loss of hair as seen with alopecia might pose a technical challenge.

In this case report, the researchers describe the utility and tolerability of HD-tDCS in a patient diagnosed with schizophrenia with persistent AVH with comorbid alopecia universalis (AU).

Reference

Parlikar, R., Selvaraj, S., Shiva, L., Sreeraj, V.S., Venkatasubramanian, G. & Chandra, P.S. (2019) Successful application of add-on high-definition transcranial direct current stimulation in a schizophrenic patient with comorbid alopecia universalis.

Electroconvulsive Therapy (ECT) in Treatment-Resistant Schizophrenia & Coexisting Myasthenia Gravis (MG)

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Research Paper Title

Successful administration of electroconvulsive therapy in a patient with treatment-resistant schizophrenia and coexisting myasthenia gravis.

Background

Electroconvulsive therapy (ECT) is an efficacious treatment for resistant schizophrenia.

However, the presence of comorbid myasthenia gravis (MG) poses considerable challenge and concerns for administering anesthesia during ECT.

To the best of the researchers knowledge, till this date, there is only a solitary case reporting the use of ECT in schizophrenia with coexisting MG.

Hence, in this case report, they describe successful administration of modified ECT under anaesthesia in a patient with treatment-resistant schizophrenia with MG.

Reference

Sreeraj, V.S., Venkataramaiah, S., Sunka, A., Kamath, S. & Rao, N.P. (2019) Successful administration of electroconvulsive therapy in a patient with treatment-resistant schizophrenia and coexisting myasthenia gravis. Indian Journal of Psychiatry. 61(6), pp.653-654. Available from World Wide Web: http://www.indianjpsychiatry.org/text.asp?2019/61/6/653/270349. [Accessed: 16 February, 2020].

Development and Implementation of a Hospital-Based Clinical Practice Guideline to Address Paediatric Somatic Symptom and Related Disorders

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Research Paper Title

Taking the Pain out of Somatisation: Development and Implementation of a Hospital-Based Clinical Practice Guideline to Address Paediatric Somatic Symptom and Related Disorders.

Background

The diagnostic category of somatic symptom and related disorders (SSRDs), although common, is often poorly recognized and suboptimally managed in inpatient pediatric care.

Little literature exists to address SSRDs in the inpatient paediatric setting.

The purpose of the study was to characterise current SSRD practice, identify problem areas in workflow, and develop a standardised approach to inpatient evaluation and management at a tertiary care academic children’s hospital.

Methods

A multidisciplinary group identified patients with SSRD admitted between May 2012 and October 2014.

A retrospective chart review on a convenience sample was performed to identify population characteristics and current practice.

Lean methodology was used to define current state practice and future state intervention.

These methods were used to guide identification of problem areas, which informed protocol, a clinical practice guideline, and resource development.

Results

Thirty-six patients aged 8 to 17 years met inclusion criteria for chart review.

Most patients presented with either neurological or pain-related complaints.

The mean length of stay was 5.44 days (SD = 6.3), with few patients receiving a mental health consultation within 24 hours of hospitalisation.

Patients averaged 5.8 medical and/or psychiatric diagnoses on discharge (SD = 5.2), and two-thirds did not have an SSRD diagnosis.

Half of patients had co-morbid psychiatric diagnoses, whereas one-quarter were discharged with no mental health follow-up.

Conclusions

In this study, the researchers describe the process and content development of a single-site institutional protocol, clinical practice guideline, and resources for the evaluation and management of paediatric SSRDs.

This study may serve as a model for similar standardisation of SSRD care in other inpatient paediatric medical settings.

Reference

Kullgren, K.A., Shefler, A., Malas, N., Monroe, K., Leber, S.M., Sroufe, N., El Sakr, A., Pomeranz, E., O’Brien, E. & Mychaliska, K.P. (2020) Taking the Pain out of Somatization: Development and Implementation of a Hospital-Based Clinical Practice Guideline to Address Pediatric Somatic Symptom and Related Disorders. Hospital Paediatrics. 10(2), pp.105-113. doi: 10.1542/hpeds.2019-0141. Epub 2020 Jan 2.

Analysis of Voluntary vs Involuntary Admissions

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Research Paper Title

Voluntary admissions for patients with schizophrenia: A systematic review and meta-analysis.

Background

Voluntary admission rates of schizophrenia vary widely across studies.

In order to make the topic be informed by evidence, it is important to have accurate estimates.

This meta-analysis examined the worldwide prevalence of voluntary admissions for patients with schizophrenia.

Methods

PubMed, EMBASE, PsycINFO, the Cochrane Library, Web of Science and Medline databases were systematically searched, from their commencement date until 19th November 2018.

Meta-analysis of included studies was performed using the random-effects model.

Results

Thirty-five studies with 134,100 schizophrenia patients were included.

The overall voluntary admission rate of schizophrenia was 61.9 % (95 %CI: 52.3 %-70.7 %), while the involuntary rate was 43.0 % (95 %CI: 34.8 %-51.7 %).

Subgroup analyses revealed that patients in Europe had significantly higher voluntary admission rates, while their North American counterparts were more likely admitted involuntarily.

Papers published prior to 2008 reported higher involuntary admission rates.

Meta-regression analyses showed that higher male percentage and higher study quality were significantly associated with higher voluntary admission rate.

Conclusions

Although the worldwide prevalence of voluntary admissions was higher than that of involuntary admissions, the latter was common for schizophrenia.

With the continuing liberalisation of mental health laws broadening community-based psychiatric services, the rate of voluntary psychiatric admissions is expected to further increase over time.

Reference

Yang, Y., Li, W., Lok, K.I., Zhang, Q., Hong, L., Ungvari, G.S., Bressington, D.T., Cheung, T. & Xiang, Y.T. (2019) Voluntary admissions for patients with schizophrenia: A systematic review and meta-analysis. Asian Journal of Psychiatry. 48:101902. doi: 10.1016/j.ajp.2019.101902. [Epub ahead of print].

Can CBD Capsules Treat Cannabis Addiction?

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For individuals who are addicted to cannabis, one treatment option may be, paradoxically, to take pills that contain an extract of the drug.

The first test of the idea has found that indiviudals taking capsules of this extract, known as cannabidiol (CBD), nearly halved the amount of cannabis they smoked, according to recent research.

Cannabis is often seen as a soft drug, but according to one estimate about one in 10 people can become addicted, getting withdrawal symptoms such as anxiety when they try to stop using it.

The number of individuals seeking treatment because they can not quit smoking cannabis has been rising in the past decade, linked with use of the more potent form known as skunk.

There are two main psychoactive substances in cannabis:

  • The first is CBD; and
  • The second is the compound is tetrahydrocannabinol (THC).

THC is responsible for the drug’s high and, while THC tends to increase anxiety, CBD calms – it gets rid of eh toxic effects of THC.

In a recent study, Val Curran and her colleagues at the University College London, ran a trial in which participants took CBD for four weeks to alleviate withdrawal symptoms to help them quit smoking cannabis.

The trial involved 82 individuals classed as severely addicted to the drug, who were given one of three different doses of CBD in capsule form or a placebo (they all, also, had psychological support).

  • The middle dose of 400 milligrams worked best – after six months, it halved the amount of cannabis each individual used compared with placebo, as shown by tests for THC in their urine.
    • The 400 milligram dose also more than doubled the number of days when individuals had no THC in their urine.
  • The highest dose of 800 milligrams was slightly less effective than the middle one.
  • The lowest dose did not work.

A previous study has shown that individuals can also be helped to quit smoking cannabis by treatment with Sativex, a cannabis extract with both CBD and THC, deployed in a similar way to nicotine replacement therapy for tobacco users.

Academics suggest there could be advantages to using CBD alone. CBD has a variety of anti-addictive properties.

Researchers are also investigating CBD as a treatment for alcohol addiction. Two of the main features during alcohol detoxification are:

  • Severe anxiety; and
  • Risk of seizures.

It is believed that CBD has very strong anxiety-reducing properties, but this is still being researched.

Curran’s study also found preliminary evidence that CBD may help individuals to give up smoking tobacco.

CBD supplements are increasingly sold in pharmacies and health food shops as remedies for a range of illnesses, but at much lower doses than those used in Curran’s trial.

Many of the health claims made for them are not (currently) based on evidence. Therefore the current advice is that anyone who cannot stop smoking cannabis should seek medical assistance.

Reference

New Scientist. (2019) CBD Capsules May Treat Cannabis Addiction. New Scientist. 19 October 2019, pp.9.

Rehabilitation Programmes: Interventions & Evidence

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Research Paper Title

Addressing Severe Mental Illness Rehabilitation in Colombia, Costa Rica, and Peru.

Background

Many Latin American countries face the challenge of caring for a growing number of people with severe mental illnesses while promoting deinstitutionalisation and community-based care.

This article presents an overview of current policies that aim to reform the mental health care system and advance the employment of people with disabilities in Colombia, Costa Rica, and Peru.

Methods

The authors conducted a thematic analysis by using public records and semi-structured interviews with stakeholders.

Results

The authors found evidence of supported employment programmes for vulnerable populations, including people with disabilities, but found that the programs did not include people with severe mental illnesses.

Five relevant themes were found to hamper progress in psychiatric vocational rehabilitation services:

  1. Rigid labour markets;
  2. Insufficient advocacy;
  3. Public subsidies that create conflicting incentives;
  4. Lack of deinstitutionalised models; and
  5. Lack of reimbursement for evidence-based psychiatric rehabilitation interventions.

Policy reforms in these countries have promoted the use of medical interventions to treat people with severe mental illnesses but not the use of evidence-based rehabilitation programmes to facilitate community integration and functional recovery.

Conclusions

Because these countries have other supported employment programmes for people with non-psychiatric disabilities, they are well positioned to pilot individual placement and support to accelerate full community integration among individuals with severe mental illnesses.

Reference

Cubillos, L., Muñoz, J., Caballero, J., Mendoza, M., Pulido, A., Carpio, K., Udutha, A.K., Botero, C., Borrero, E., Rodríguez, D., Cutipe, Y., Emeny, R., Schifferdecker, K. & Torrey, W.C. (2020) Addressing Severe Mental Illness Rehabilitation in Colombia, Costa Rica, and Peru. Psychiatric Services (Washington, D.C.). doi: 10.1176/appi.ps.201900306. [Epub ahead of print].

Benzodiazepine & Prescribing Behaviour

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Research Paper Title

An Intervention to Decrease Benzodiazepine Prescribing by Providers in an Urban Clinic.

Background

The objective of this quality improvement project was to decrease the amount of benzodiazepines (BZDs) prescribed by providers at a Midwestern university outpatient clinic.

Methods

Clinic providers participated in a brief, live educational intervention combining academic detailing (i.e., the provision of current evidence about BZD) and pharmaceutical detailing (i.e., a sales technique borrowed from pharmaceutical companies).

A 1% decrease in BZD prescribing was set as the measure of success.

Using data from the electronic medical record, the monthly average of BZD prescriptions written within calendar year 2017 (before project launch) was compared to the number written 30 days after the intervention.

Results

Following the intervention, an 80% reduction in BZD prescribing was calculated.

Conclusions

Combined academic and pharmaceutical detailing could be an effective way to change prescribing behaviour in this provider population.

Further investigation is needed to ascertain whether the change in prescribing behaviour can be sustained, and that no harm is being done to patients who are currently dependent on BZD medications.

Reference

Platt, L., Savage, T.A. & Rajagopal, N. (2020) An Intervention to Decrease Benzodiazepine Prescribing by Providers in an Urban Clinic. Journal of Psychosocial Nursing and Mental Health Services. 58(1), pp.39-45. doi: 10.3928/02793695-20191218-08.

Talking about Benzodiazepine Use with Patients

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Research Paper Title

Let’s Talk About Benzodiazepine Use: Inpatient Psychiatric Nurses Initiating the Conversation.

Background

Inpatient psychiatric nurses regularly dispense pro re nata (PRN) medication to individuals during their psychiatric hospitalisation.

International studies indicate that 66% to 90% of patients receive PRN medications during hospitalisation, a large percentage of which are benzodiazepines (BZDs).

Although clear opportunities exist for nursing intervention to reduce BZD use, there is little recent US literature on inpatient psychiatric nurses’ proactive approach to the issue.

The current article examines the factors that support BZD use during inpatient hospitalisation, including nurses’ attitudes around BZD use, the perceived effectiveness of the medication to address difficult situations, and the barriers to using alternative nonpharmacological methods.

Suggestions are presented for how nurses might begin dialogues with patients around BZD use and alternative strategies to manage distress.

It is recommended that the specialty initiate a research agenda for reducing BZD use during inpatient psychiatric treatment and champion the issue as a focus for systematic improvement efforts.

Reference

Delaney, K.R. (2020) Let’s Talk About Benzodiazepine Use: Inpatient Psychiatric Nurses Initiating the Conversation.