Using implementation intentions to prevent relapse after remission from psychological treatment for depression: The SMArT intervention.

OBJECTIVE: To provide evidence of the effectiveness of a brief relapse prevention intervention using implementation intentions (Self-Management after Therapy, SMArT), following remission from depression and to identify effective relapse prevention strategies. METHOD: The SMArT intervention was provided to 107 patients who were recovered after psychological therapy for depression. Relapse events were calculated as reliable and clinically significant increases in PHQ-scores. Sixteen patients receiving the intervention and eight practitioners providing it were interviewed. Framework Analysis identified seven themes which highlighted effective relapse prevention strategies and effective implementation of the SMArT intervention. RESULTS: Relapse rates at the final SMArT session (four months after the end of acute stage therapy) were 11%. Seven themes were identified that supported effective self-management: (1) Relationship with the practitioner-feeling supported; (2) Support networks; (3) Setting goals, implementing plans and routine; (4) Changing views of recovery; (5) The SMArT sessions-mode, content, timing, duration; (6) Suitability for the person; and (7) Suitability for the service. CONCLUSION: The study provides some support for the effectiveness of the SMArT intervention, although a randomized controlled trial is required; and identifies important relapse prevention strategies.

Creating better doctors: exploring the value of learning medicine in primary care.

BACKGROUND: Across the UK, 13% of undergraduate medical education is undertaken in primary care (PC). Students value their experiences in this setting but uncertainty remains about the extent to which these placements influence their future practice. AIMS: To explore the impact of PC based undergraduate medical education on the development of medical students and new doctors as clinicians, and on students' preparedness for practice. METHODS: Mixed method study across two UK medical schools. Focus groups and individual interviews with Year 5 medical students, Foundation Year 2 doctors and GP Specialty Trainees; online surveys of Year 5 medical students and Foundation Year 2 doctors. RESULTS: PC placements play an important part in the development of all 'apprentice' doctors, not just those wanting to become GPs. They provide a high quality learning environment, where students can: gradually take on responsibility; build confidence; develop empathy in their approach to patient care; and gain understanding of the social context of health and illness. CONCLUSIONS: The study suggests that for these results to be achieved, PC placements have to be high quality, with strong links between practice-based learning and teaching/assessment in medical school. GP tutors need to be enthusiastic and students actively involved in consultations.

Experiences, acceptability and feasibility of an isometric exercise intervention for stage 1 hypertension: embedded qualitative study in a randomised controlled feasibility trial.

BACKGROUND: Healthy lifestyle changes for patients with stage 1 hypertension are recommended before antihypertensive medication. Exercise has antihypertensive benefits; however, low adoption and high attrition are common. Patients need easily adoptable, effective and manageable exercise interventions that can be sustained for life. We present participant and stakeholder perceptions of an isometric exercise intervention for stage 1 hypertension delivered in the National Health Service (NHS, UK). METHODS: An embedded qualitative study within a randomised-controlled feasibility study included intervention arm participants (n = 10), healthcare professionals from participating NHS sites (n = 3) and non-participating NHS sites (n = 5) taking part in semi-structured interviews to explore feasibility of delivering an isometric exercise intervention within the study design and an NHS context. Data was analysed using reflective thematic analysis. RESULTS: Three themes were identified: study deliverability; motivators and barriers; support for study participation. Findings indicated that the study was well designed. Health benefits, unwillingness to take medication, altruism and interest in the study helped motivation and adherence. Study support received was good, but healthcare professionals were insecure in intervention delivery with regular training/supervision needed. Perception of health improvement was mixed, but, in some, uptake of wider lifestyle changes resulted from participation. Stakeholders felt that current service challenges/demand would make implementation challenging. CONCLUSIONS: Despite participant positivity, delivery of an isometric intervention in an NHS setting was considered challenging given the current service demand, although possible with robust effectiveness evidence. Findings support further effectiveness data and implementation development of the isometric exercise intervention. TRIAL REGISTRATION: ISRCTN, ISRCTN13472393 . Registered 18 September 2020.

Delivering clinical studies of exercise in the COVID-19 pandemic: challenges and adaptations using a feasibility trial of isometric exercise to treat hypertension as an exemplar.

The COVID-19 pandemic has significantly impacted on the delivery of clinical trials in the UK, posing complicated organisational challenges and requiring adaptations, especially to exercise intervention studies based in the community. We aim to identify the challenges of public involvement, recruitment, consent, follow-up, intervention and the healthcare professional delivery aspects of a feasibility study of exercise in hypertensive primary care patients during the COVID-19 pandemic. While these challenges elicited many reactive changes which were specific to, and only relevant in the context of 'lockdown' requirements, some of the protocol developments that came about during this unprecedented period have great potential to inform more permanent practices for carrying out this type of research. To this end, we detail the necessary adaptations to many elements of the feasibility study and critically reflect on our approach to redesigning and amending this ongoing project in order to maintain its viability to date. Some of the more major protocol adaptations, such as moving the study to remote means wherever possible, had further unforeseen and undesirable outcomes (eg, additional appointments) with regards to extra resources required to deliver the study. However, other changes improved the efficiency of the study, such as the remote informed consent and the direct advertising with prescreening survey. The adaptations to the study have clear links to the UK Plan for the future of research delivery. It is intended that this specific documentation and critical evaluation will help those planning or delivering similar studies to do so in a more resource efficient and effective way. In conclusion, it is essential to reflect and respond with protocol changes in the current climate in order to deliver clinical research successfully, as in the case of this particular study.

Using photovoice to understand and improve healthy lifestyles of people diagnosed with serious mental illness.

WHAT IS KNOWN ON THE SUBJECT?: People diagnosed with serious mental illness (SMI): Live 10 to 20 years less than the general population, and this can be related to lifestyle factors such as poor diet and low levels of physical activity. Have a good understanding of what healthy lifestyle comprises of, but face barriers and challenges related to their mental health, treatment, and life situation. There is limited participatory research that considers the specific beliefs of people diagnosed with SMI about what "being healthy" means to them. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE: People diagnosed with SMI value health and are often already engaged in activities that promote both physical and mental health. They experience the "vicious cycle" of barriers to engage in healthier lifestyle, including medication effects, poor sleep routines, fatigue, low mood and establishing a routine, but this shows how healthy activities can improve their mental health. The importance of meaningful places and their role in supporting healthy lifestyles was identified Some people diagnosed with SMI face significant socio-economic challenges (such as lack of cooking facilities; limited money for purchasing healthy food) to support healthy lifestyles. To truly understand the perspectives of people with SMI, who are typically voiceless and disempowered, research methods need to allow the participants to set the agenda for discussion, to not only provide rich data but also have the added benefit of empowerment and enhanced engagement. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Mental health nurses should: Explore the practical barriers to healthy lifestyle such as financial concerns and ensure that people can access support to obtain what they need from the local community resources. Instigate a mental health and/or medication review if mental health symptoms or medication side effects are a barrier to healthy lifestyles Explore what places have meaning and consider how to use meaningful places as motivating factors for healthy lifestyles and promoting mental well being. ABSTRACT: INTRODUCTION: People diagnosed with serious mental illness (SMI) live 10-20 years less than the general population, due in part to co-existing physical illness linked to lifestyle factors. To inform individualized care plans to promote healthy lifestyles, it is important to understand the views of people diagnosed with SMI. To truly understand their lived experience, research methods should allow participants to set the agenda for discussion, enhancing engagement and empowerment in the research process. AIM: To use a participatory research approach to capture what healthy lifestyle means to people who are diagnosed with SMI. METHOD: Eight people diagnosed with SMI participated in six, weekly focus groups using Photovoice. Data were analysed using thematic analysis. RESULTS: The overarching theme was 'mental health is the main priority', and the other themes were barriers to a healthy lifestyle, represented as a vicious cycle, and three themes, which were facilitators - the importance of place, meaningful activities, and the importance of others. DISCUSSION: The methodology allowed participants to choose images that reflected their lived experience. The themes describe the interaction of physical and mental health and practical barriers and will inform the design of individualized care plans. IMPLICATIONS FOR PRACTICE: In co-designing care plans, mental health nurses should draw on peoples' preferences and explore the barriers identified in this study.

'Out of Hospital': a scoping study of services for carers of people being discharged from hospital.

Successive government policies have highlighted the need to inform and involve carers fully in the hospital discharge process. However, some research suggests that many carers feel insufficiently involved and unsupported in this process. This paper summarises a scoping review to identify what the UK literature tells us about the service provision for carers, and its effectiveness, around the time of hospital discharge of the care recipient, and also describes a mapping exercise of the work currently being done by Princess Royal Trust for Carers Centres in England to support carers around the time of hospital discharge. The restriction to UK literature was dictated by the nature of the project; a modest review carried out for a UK-based voluntary sector organization. Fifty-three documents were reviewed, of which 19 papers (representing 17 studies) were reporting on primary research. As only five of these studies actually involved an intervention, it appears there is very little research from the UK which evaluates specific interventions to support carers around the time of hospital discharge of the care recipient. While the mapping exercise showed that in some areas there are services and/or initiatives in place which have been designed to improve the process of discharge for carers, in many places there is still a gap between what policy and research suggest should happen and what actually happens to carers at this time. Even where services and initiatives to support carers through the discharge process exist, there is only limited evidence from research or evaluation to demonstrate their impact on the carer's experience. Further research, both quantitative and qualitative, is required to address these areas and enable commissioners, providers and carers' organizations to work together towards a service in which patients and carers alike receive the support and help they need at this significant time of transition.