Digital-Based Interventions for Complex Post-Traumatic Stress Disorder: A Systematic Literature Review.

Research has shown that complex post-traumatic stress disorder (cPTSD) differs from post-traumatic stress disorder (PTSD) on core symptoms relating to the individual's sense of self, and this has driven the need for treatment approaches to address these specific features of cPTSD. The COVID-19 pandemic has led to the increased use of digital-based interventions (DBIs) to treat mental illnesses, including trauma-related disorders. However, while evidence for the use of DBIs for PTSD has previously been synthesized, the current review is the first synthesis of research on the use of DBIs for cPTSD. A systematic search of Scopus, PsychINFO, and EBSCOhost was conducted, using search terms targeting "cPTSD" and "DBIs," to identify research on the use of DBIs to treat cPTSD symptoms. Ten papers were identified, which provided preliminary evidence for the efficacy of DBIs to reduce cPTSD symptoms. Further, DBIs were reported as acceptable by individuals with a history of complex trauma. The paper also provides insight into the therapeutic approaches adopted, digital modalities utilized, safety measures included, and whether/to what degree support was provided. While DBIs show promise for treating cPTSD, there is substantial room for advancement of the empirical evidence base for these approaches. Both clinical and research-based recommendations are provided separately.

A qualitative evaluation of a co-design process involving young people at risk of suicide.

BACKGROUND: Co-design is becoming common practice in the development of mental health services, however, little is known about the experience of such practices, particularly when young people are involved. OBJECTIVE: The aim of this study was to conduct a process evaluation of the co-design which was undertaken for the development of an intervention for youth and adolescents at risk of suicide. This paper briefly outlines the co-design process undertaken during a COVID-19 lockdown and then focuses on a qualitative evaluation of the experience of taking part in a co-design process. SETTING AND PARTICIPANTS: The evaluation involved young consumers of a public youth mental health service, their carers/parents and service delivery staff who had taken part in the co-design process. METHOD: This study used follow-up semistructured interviews with the co-design participants to explore their experience of the co-design process. Inductive thematic analysis was used to draw out common themes from the qualitative data. RESULTS: It was found that despite the practical efforts of the project team to minimise known issues in co-design, challenges centred around perceptions regarding power imbalance, the need for extensive consultation and time constraints still arose. DISCUSSION: Despite these challenges, the study found that the co-design provided a human-centred, accessible and rewarding process for young people, parents and staff members, leaving them with the feeling that they had made a worthwhile contribution to the design of the new service, as well as contributing to changing practice in service design. CONCLUSION: With sensitivity and adaptation to usual practice, it is possible to include young people with suicidal ideation, their parents/carers and professional staff in a safe and effective co-design process. PATIENT AND PUBLIC CONTRIBUTION: The authors would like to thank and acknowledge the young people with a lived experience and their carers who participated in the co-design process and research evaluation component of this study. We also wish to thank the clinical staff, peer workers and family peer workers who participated in this research.

Are codesigned programmes more difficult to implement? A qualitative study of staff perceptions on the implementation of a new youth mental health programme.

BACKGROUND: Codesigned interventions are becoming more common in health services and, in particular, in the design and development of mental health programmes and interventions. However, previous research has established that the transition from codesign to implementation can experience several challenges and that this transition process has received little research attention. OBJECTIVE: The aim of this study was to explore the experience of staff members charged with the implementation of a codesigned intervention for young people and adolescents at risk of suicide. SETTING AND PARTICIPANTS: Five staff members involved in the implementation of the new codesigned programme took part in semi-structured interviews. METHOD: The study involved qualitative evaluation of staff experiences during the implementation of a new child and youth suicide intervention. Interviews were analysed using reflexive thematic analysis. RESULTS: The analysis identified four themes of 'disconnect', 'operational challenges, 'service user' and 'being authentic'. 'Disconnect' captures the difficulties of implementing a codesigned programme which leads to 'operational challenges' in meeting broader expectations while ensuring the feasibility of the programme. The third theme, 'service user', captures the realisation that the young people accessing the new service were different to those involved in the codesign process. The final theme, 'being authentic', highlights how staff needed to be responsive and flexible while remaining true to the principles proposed in the codesign. DISCUSSION: This study yielded some valuable insights into the challenges around the implementation of a codesigned intervention, an under-researched area. The findings suggest that adaption of the design may be necessary, if it is not informed by implementation constraints, making it necessary for the implementation team to be well-briefed on the initial design and given plenty of time to make the necessary adjustments in a coproduction process. Limitations for the generalisation of the results include a small sample of staff and particular challenges that may be unique to this study. CONCLUSION: The present study highlights that for health services undertaking codesign approaches, appropriate time and resources need to be considered for the implementation phase of an initiative, to ensure that there is effective translation from design to implementation and that new codesigned services can be effective within operational constraints. PATIENT AND PUBLIC CONTRIBUTION: The authors would like to thank and acknowledge the young people with a lived-experience and their carers who participated in the codesign process and research evaluation component of this study. We also wish to thank the clinical staff, peer workers and family peer workers who participated in the evaluation.

A systematic review and meta-analysis of the relationship between obsessive-compulsive symptoms and symptoms of proposed orthorexia nervosa: The contribution of assessments.

OBJECTIVE: This systematic review and meta-analysis aimed to update the literature on orthorexia nervosa (ON), a proposed diagnosis of pathologically 'healthy' eating, by critically analysing the current evidence for the relationship between ON and obsessive-compulsive (OC) symptoms. Further, this paper aimed to compare the ON/OC relationship significance and strength based on when the ON measurement tool was developed. METHOD: PsycINFO, PubMed and Web of Science databases were queried for quantitative, peer-reviewed studies recruiting adult participants, published in English up to April 2023. Studies not directly comparing ON and OC symptoms were excluded. After full-text review and quality assessment, 40 studies were included in the systematic review and 31 studies in the meta-analysis. RESULTS: ON assessments created prior to the 2016 revised ON diagnostic criteria do not appear to fully capture OC symptoms. Studies using earlier developed ON assessments demonstrated inconsistent ON/OC relationships whereas studies implementing more recent assessments (from 2018 onwards) found consistently significant, larger relationships, highlighting a previously underrated OC component of ON. CONCLUSIONS: Early ON studies, and studies utilising early ON assessments should be interpreted with caution, particularly in relation to OC symptom involvement in ON. Future research should validate novel ON assessments and investigate common underlying factors.

A systematic review and meta-analysis of intensive treatment options for adults with eating disorders.

Eating disorders (EDs) are complex conditions with one of the highest mortality rates among psychiatric illnesses. While outpatient evidence-based treatments for EDs in adults exist, there is often utilisation of more intensive interventions as part of treatment. However, a comprehensive analysis of the impacts of intensive treatment (inpatient, residential and day program) on physical and psychosocial outcomes is lacking. Thus, the current systematic review and meta-analysis aimed to investigate the effectiveness of intensive treatments in adults with EDs for the outcomes of body mass index (BMI), disordered eating, depression, and quality of life, as well as a moderation analysis investigating a range of clinical characteristics. Overall, 62 studies were included in the meta-analysis. The results revealed that intensive treatment in adults yielded significant improvements in BMI (for underweight patients), disordered eating, depression, and quality of life. Treatment setting, length of stay and geographical region of the study all served as moderators for disordered eating and depression. Nevertheless, given the high heterogeneity in the meta- and moderation analyses, these results should be interpreted with caution. Future high-quality research is needed to determine the most beneficial elements of intensive treatment (compared to outpatient) in adults with EDs.

Examining health professional perspectives on social media body image movements: A qualitative exploration.

There has been a lack of investigation into the understanding of social media body image movements from the healthcare perspective. Health professionals can have a strong influence on how their patients relate to their own bodies, including experiences of weight-based discrimination. This study examined the perspectives of health professionals on body image social media movements and whether they believed they were relevant to their professional practice. This study recruited 30 medical and allied health professionals to participate in semi-structured interviews. Thematic analysis was used to generate common themes across the data. Overall, participants identified benefits associated with body positivity online content, but expressed concerns for the health status of influencers with larger bodies and that overall, the pro-anorexia movement was harmful. Despite having limited understanding and exposure to the body neutrality movement, participants generally preferred it over body positivity. Finally, participants stated that they believed that these movements were relevant to their practice, yet were rarely discussed in consults. These findings suggest there is a lack of body image-based discussions despite the relevance to patient health across multiple domains. This indicates that health professionals may benefit from social media literacy training to support thorough assessment and treatment of their patients.

Raising Suicide in Medical Appointments-Barriers and Facilitators Experienced by Young Adults and GPs: A Mixed-Methods Systematic Review.

The aim of this review was to understand the barriers and facilitators facing GPs and young adults in raising and addressing suicide in medical appointments. A mixed-methods systematic review was conducted of qualitative and quantitative studies. The focus was papers that explored barriers and facilitators experienced by young adults aged 18 to 26, and GPs working in primary care environments. Nine studies met the inclusion criteria. Four studies provided information on young adults' views, four on GPs, and one considered both GP and young adults' viewpoints. Nine barrier and seven facilitator themes were identified. Unique to this review was the recognition that young adults want GPs to initiate the conversation about suicide. They see this as a GP's responsibility. This review further confirmed that GPs lack the confidence and skills to assess suicide risk in young adults. Both findings combined could explain previous results for reduced identification of suicide risk in this cohort. GP training needs considerable focus on addressing skill deficiencies and improving GP confidence to assess suicide risk. However, introducing suicide risk screening in primary care for young adults should be a priority as this will overcome the need for young adults to voluntarily disclose thoughts of suicide.

Barriers and facilitators to treatment seeking and engagement amongst women with complex trauma histories.

Complex traumatic experiences, such as childhood sexual and physical abuse, occur in approximately 13% of the Australian population and are more common in women. Despite the prevalence of complex trauma and the need for evidence-based services for survivors, no studies have explored treatment-related experiences of women with complex trauma in Australia. The aim of the current study was to identify barriers and facilitators to treatment seeking and engagement amongst women who have experienced complex trauma in Australia. Semi-structured interviews were conducted with 11 women with complex trauma histories who presented to a university outpatient psychology clinic. Content analysis was used to identify common barriers and facilitators to mental health treatment seeking and engagement amongst these women. Participants faced three key barriers when seeking treatment and engaging in mental health services: systemic issues, dissatisfaction with treatment and intrapersonal barriers (e.g. fear of the healthcare system). Appropriate support from supportive, committed health care workers was a facilitator to engagement and access. Findings from this study suggest that the mental health system in Australia may not be meeting the needs of women with complex trauma histories. Increasing access to affordable, trauma-informed care and bolstering providers' knowledge of complex trauma, may enable some of the barriers identified by participants to be overcome.

Videoconferencing psychotherapy for couples and families: A systematic review.

The delivery of videoconferencing psychotherapy (VCP) has been found to be an efficacious, acceptable and feasible treatment modality for individual therapy. However, less is known about the use of VCP for couple and family therapy (CFT). The focus of this systematic review was to examine the efficacy, feasibility and acceptability of using VCP as a treatment delivery modality for CFT. A systematic search was conducted, data relating to efficacy, feasibility and acceptability were extracted from included studies. The search returned 7,112 abstracts, with 37 papers (0.005%) included. The methods of the review were pre-registered (PROSPERO; CRD42018106137). VCP for CFT was demonstrated to be feasible and acceptable. A meta-analysis was not conducted; however, results from the included studies indicate that VCP is an efficacious delivery method for CFT. Recommendations for future research and implications regarding clinical practice are made, which may be of interest to practitioners given the COVID-19 pandemic.

Review of the current empirical literature on using videoconferencing to deliver individual psychotherapies to adults with mental health problems.

PURPOSE: The COVID-19 pandemic has resulted in a widespread adoption of videoconferencing as a communication medium in mental health service delivery. This review considers the empirical literature to date on using videoconferencing to deliver psychological therapy to adults presenting with mental health problems. METHOD: Papers were identified via search of relevant databases. Quantitative and qualitative data were extracted and synthesized on uptake, feasibility, outcomes, and participant and therapist experiences. RESULTS: Videoconferencing has an established evidence base in the delivery of cognitive behavioural therapies for post-traumatic stress disorder and depression, with prolonged exposure, cognitive processing therapy, and behavioural activation non-inferior to in-person delivery. There are large trials reporting efficacy for health anxiety and bulimia nervosa compared with treatment-as-usual. Initial studies show applicability of cognitive behavioural therapies for other anxiety and eating disorders and obsessive-compulsive spectrum disorders, but there has yet to be study of use in severe and complex mental health problems. Therapists may find it more difficult to judge non-verbal behaviour, and there may be initial discomfort while adapting to videoconferencing, but client ratings of the therapeutic alliance are similar to in-person therapy, and videoconferencing may have advantages such as being less confronting. There may be useful opportunities for videoconferencing in embedding therapy delivery within the client's own environment. CONCLUSIONS: Videoconferencing is an accessible and effective modality for therapy delivery. Future research needs to extend beyond testing whether videoconferencing can replicate in-person therapy delivery to consider unique therapeutic affordances of the videoconferencing modality. PRACTITIONER POINTS: Videoconferencing is an efficacious means of delivering behavioural and cognitive therapies to adults with mental health problems. Trial evidence has established it is no less efficacious than in-person therapy for prolonged exposure, cognitive processing therapy, and behavioural activation. While therapists report nonverbal feedback being harder to judge, and clients can take time to adapt to videoconferencing, clients rate the therapeutic alliance and satisfaction similarly to therapy in-person. Videoconferencing provides opportunities to integrate therapeutic exercises within the person's day-to-day environment.

Barriers and facilitators of videoconferencing psychotherapy implementation in veteran mental health care environments: a systematic review.

BACKGROUND: Whilst treatment for mental health issues has traditionally been conducted in-person, advances in technology has seen a recent growth in the use of online video therapy services to help overcome access-to-care barriers faced by those living in rural locations and those unable to travel. These barriers are particularly apparent in the case of veteran populations, which is the focus of this review. Whilst the research investigating the efficacy of online video therapy to treat mental health issues among veterans is promising, widespread adoption and utilisation of this modality remains low with efforts often failing to progress past the pilot phase to implementation. This review focuses on the implementation of online video therapy in veteran mental health care settings and aims to identify the potential barriers and facilitators relevant to implementing the modality in military organisations. METHODS: A systematic search of three databases (PsycInfo, PubMed, and Web of Science) was conducted. To be eligible for inclusion, studies had to investigate the challenges, lessons learnt, or factors operating as barriers and/or facilitators to the implementation of online video therapy in veteran health care systems. RESULTS: The initial search revealed a total of 202 articles. This was reduced to 133 when duplicates were removed. After screening the titles and abstracts a further 70 articles were excluded leaving 63 to be retrieved for full review. A total of 10 studies were included in this review. The most commonly reported barriers were related to clinician concerns, logistical problems, and technology. Other barriers included access to resources as well as challenges posed by collaborations, policy and recruitment. Facilitators included experience using the modality and having dedicated staff responsible for promoting and managing the new service (e.g., on-site champions and telehealth technicians). CONCLUSIONS: This review suggests that numerous barriers must be identified and addressed before attempting to implement an online video therapy service in veteran organisations. Further research is needed to establish best practice for implementation, particularly across geographically dispersed sites. It is hoped that the findings of this review will be used to help inform future implementation efforts and research initiatives in this space.

Videoconferencing Psychotherapy in the Public Sector: Synthesis and Model for Implementation.

BACKGROUND: Videoconferencing psychotherapy (VCP) is a growing practice among mental health professionals. Early adopters have predominantly been in private practice settings, and more recent adoption has occurred in larger organizations, such as the military. The implementation of VCP into larger health service providers in the public sector is an important step in reaching and helping vulnerable and at-risk individuals; however, several additional implementation challenges exist for public sector organizations. OBJECTIVE: The aim of this study was to offer an implementation model for effectively introducing VCP into public sector organizations. This model will also provide practical guidelines for planning and executing an embedded service trial to assess the effectiveness of the VCP modality once implemented. METHODS: An iterative search strategy was employed, drawing on multiple fields of research across mental health, information technology, and organizational psychology. Previous VCP implementation papers were considered in detail to provide a synthesis of the barriers, facilitators, and lessons learned from the implementation attempts in the military and other public sector settings. RESULTS: A model was formulated, which draws on change management for technology integration and considers the specific needs for VCP integration in larger organizations. A total of 6 phases were formulated and were further broken down into practical and measurable steps. The model explicitly considers the barriers often encountered in large organizational settings and suggests steps to increase facilitating factors. CONCLUSIONS: Although the model proposed is time and resource intensive, it draws on a comprehensive understanding of larger organizational needs and the unique challenge that the introduction of VCP presents to such organizations.

Multivariate pattern analysis of event-related potentials predicts the subjective relevance of everyday objects.

Potentially decision-relevant stimuli have been proposed to undergo immediate semantic processing. The current study investigated whether information regarding the general desirability ('Wanting') of visually presented 'everyday' objects was rapidly and automatically processed. Participants completed a foreground task while their electroencephalogram (EEG) was recorded, and task-irrelevant images were presented in the background. Following this, participants rated the images with regards to Wanting and the potentially related attributes of Relevance, Familiarity, Aesthetic Pleasantness and Time Reference. Multivariate pattern classification was used to predict the ratings from patterns of EEG data. Prediction of Wanting and Relevance was possible between 100 and 150ms following stimulus presentation. The other dimensions could not be predicted. Wanting and Relevance ratings were highly correlated and displayed similar feature weight maps. The current results suggest that the general desirability and subjective relevance of everyday objects is rapidly and automatically processed for a wide range of visual stimuli.

APETALA2/ETHYLENE RESPONSE FACTOR and basic helix-loop-helix tobacco transcription factors cooperatively mediate jasmonate-elicited nicotine biosynthesis.

Transcription factors of the plant-specific apetala2/ethylene response factor (AP2/ERF) family control plant secondary metabolism, often as part of signalling cascades induced by jasmonate (JA) or other elicitors. Here, we functionally characterized the JA-inducible tobacco (Nicotiana tabacum) AP2/ERF factor ORC1, one of the members of the NIC2-locus ERFs that control nicotine biosynthesis and a close homologue of ORCA3, a transcriptional activator of alkaloid biosynthesis in Catharanthus roseus. ORC1 positively regulated the transcription of several structural genes coding for the enzymes involved in nicotine biosynthesis. Accordingly, overexpression of ORC1 was sufficient to stimulate alkaloid biosynthesis in tobacco plants and tree tobacco (Nicotiana glauca) root cultures. In contrast to ORCA3 in C. roseus, which needs only the GCC motif in the promoters of the alkaloid synthesis genes to induce their expression, ORC1 required the presence of both GCC-motif and G-box elements in the promoters of the tobacco nicotine biosynthesis genes for maximum transactivation. Correspondingly, combined application with the JA-inducible Nicotiana basic helix-loop-helix (bHLH) factors that bind the G-box element in these promoters enhanced ORC1 action. Conversely, overaccumulation of JAZ repressor proteins that block bHLH activity reduced ORC1 functionality. Finally, the activity of both ORC1 and bHLH proteins was post-translationally upregulated by a JA-modulated phosphorylation cascade, in which a specific mitogen-activated protein kinase kinase, JA-factor stimulating MAPKK1 (JAM1), was identified. This study highlights the complexity of the molecular machinery involved in the regulation of tobacco alkaloid biosynthesis and provides mechanistic insights about its transcriptional regulators.