Association of admission serum sodium and outcomes following out-of-hospital cardiac arrest.

BACKGROUND: The prognostic association between dysnatremia and outcomes in out-of-hospital cardiac arrest (OHCA) is not well understood. Given hypernatremia is associated with poor outcomes in critical illness and hyponatremia may exacerbate cerebral edema, we hypothesized that dysnatremia on OHCA hospital admission would be associated with worse neurological outcomes. METHODS: We studied adults (≥19 years) with non-traumatic OHCA between 2009 and 2016 who were enrolled in the British Columbia Cardiac Arrest Registry and survived to hospital admission at 2 quaternary urban hospitals. We stratified cases by admission serum sodium into hyponatremic (<135 mmol/L), normonatremic (135-145 mmol/L), and hypernatremic (>145 mmol/L) groups. We used logistic regression models, adjusted for age, sex, shockable rhythm, admission serum lactate, and witnessed arrest, to estimate the association between admission sodium and favorable neurological outcome (cerebral performance category 1-2 or modified Rankin scale 0-3). RESULTS: Of 414 included patients, 63 were hyponatremic, 330 normonatremic, and 21 hypernatremic. In each respective group, 21 (33.3%), 159 (48.2%), and 3 (14.3%) experienced good neurological outcomes. In univariable models, hyponatremia (OR 0.53, 95% CI 0.30-0.93) and hypernatremia (OR 0.19, 95% CI 0.05-0.65) were associated with lower odds of good neurological outcomes compared to the normonatremia group. After adjustment, only hypernatremia was associated with lower odds of good neurological outcomes (OR 0.22, 95% CI 0.05-0.98). CONCLUSIONS: Hypernatremia at admission was independently associated with decreased probability of good neurological outcomes at discharge post-OHCA. Future studies should focus on elucidating the pathophysiology of dysnatremia following OHCA.

Outcomes of psychological support skills training for cancer care staff: Skill acquisition, work engagement, mental wellbeing and burnout.

OBJECTIVE: Psychological support skills training has the potential to improve both the ability of cancer staff to help their patients, and staff wellbeing. However, few recent studies have assessed both these outcomes or incorporated current developments in psychological skills training, such as deliberate practice, which includes the use of iterative, corrective feedback to identify and improve individualised skill deficits. No studies have evaluated the contribution that psychological skills training could make to cancer care staff wellbeing and expertise in the wake of the COVID-19 pandemic. This study aimed to evaluate staff skill acquisition and work-related wellbeing following psychological support skills training that applied deliberate practice principles. METHOD: A 2-day training and monthly supervision was offered to 145 cancer care staff that focused on brief assessment and intervention skills for patients experiencing mental health problems after cancer diagnosis and treatment. Deliberate practice principles were used to focus training on skills practice and feedback, over technique description. Self-reported ability to perform key skills taught, staff mental wellbeing, work engagement, and burnout were assessed at baseline, 3-month and 8-month follow-up. RESULTS: Significant improvements in skills, mental wellbeing, burnout and work engagement were reported at 8-month follow-up. Full engagement in both training sessions was predicted by poorer baseline mental wellbeing, more positive evaluation of initial training, supervision attendance, and shorter follow-up. CONCLUSION: A 2-day psychological support skills training using deliberate practice principles may support improvement in staff skill, mental wellbeing, burnout and work engagement.

Examining anxiety and depression in haematology cancer patients in ongoing treatment and under watchful waiting: A systematic review and meta-analysis.

INTRODUCTION: The present review aimed to establish prevalence rates of anxiety and depression in adults with haematology cancer, with a focus on the differences between patients under treatment and patients under watchful waiting. METHOD: Five databases (Scopus, Medline, PsycINFO, EThOS, CINAHL) were searched throughout June 2021. Key search terms included haematology cancer, anxiety, depression, in treatment and watchful waiting. Study and sample characteristics, prevalence rates and mean self-reported scores of anxiety and depression data were extracted. RESULTS: A total of 18 eligible papers were included in the review. Quality appraisal indicated papers were of adequate standard. Depression data from 2720 participants (14.5% under watchful waiting) and anxiety data from 2520 participants (15.9% under watchful waiting) were analysed through subgroup meta-analyses. The prevalence of anxiety was 34% amongst adults receiving treatment and 24.5% amongst those under watchful waiting. The prevalence of depression amongst adults receiving treatment was 31.3%, significantly higher than 16.1% of adults under watchful waiting. CONCLUSION: Overall, adults with haematology cancer were at greater risk of experiencing anxiety and depression than the general population, with greatest risk in those under treatment. The findings indicate the need for future research to examine availability and effectiveness of targeted psychological interventions.

The predictive value of patient, therapist, and in-session ratings of motivational factors early in remote cognitive behavioural therapy for severe health anxiety.

OBJECTIVES: Remote psychotherapy and the prevalence of Severe Health Anxiety (SHA) are both growing as a result of the COVID-19 pandemic. Remotely delivered Cognitive Behavioural Therapy (rCBT) for SHA is evidenced as effective, but many who seek help do not benefit. Motivational processes can influence outcomes, but it is unclear what assessment methods offer the best clinical utility in rCBT for SHA. DESIGN: This study compared the predictive validity of patient, therapist and in-session ratings of motivational factors taken at session two of rCBT for SHA among high healthcare users experiencing multimorbidity. METHODS: Motivational factors were assessed for 56 participants who attended at least two sessions of CBT for SHA delivered via video-conferencing or telephone. Following session two, therapists and patients completed online assessments of patient motivation. Two trained observers also rated motivational factors and therapeutic alliance from in-session interactions using session two recordings and transcripts. Multilevel modelling was used to predict health anxiety and a range of secondary health outcomes from motivation assessments. RESULTS: Where patients were more actively engaged in discussion of positive changes during session two, greater outcome improvements ensued in health anxiety and all secondary outcomes. Conversely, larger proportions of session two spent describing problems predicted poorer outcomes. Therapist and patient assessments of motivation did not predict health anxiety, but therapist assessments of client confidence and motivation predicted all secondary outcomes. CONCLUSIONS: Motivation remains an important process in CBT when delivered remotely, and motivational factors may predict outcomes more consistently from in-session interactions, compared to self-reports.

Impact of oral soluble guanylate cyclase stimulators in heart failure: A systematic review and Meta-analysis of randomized controlled trials.

BACKGROUND: Soluble guanylate cyclase (sGC) stimulators are a novel class of medications with emerging role in heart failure (HF). The aim of this study is to evaluate the efficacy and safety of oral sGC stimulators in patients with HF with reduced and preserved ejection fraction (HFrEF and HFpEF) by pooling data from all available randomized control trials (RCT). METHODS: A comprehensive search of electronic databases from 2000-2020 was performed. Seven RCTs, three HFrEF and four HFpEF studies, were identified. The follow-up duration ranged from 1 month to a median of 10.8 months. A random-effects meta-analysis was conducted to summarize the studies. RESULTS: The study population included 7190 patients: 5707 HFrEF and 1483 HFpEF patients. In HFrEF, oral sGC stimulators reduced the composite incidence of HF hospitalization and cardiovascular death (hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.78-0.97; I2 = 0%), primarily driven by lower HF hospitalization (HR 0.88, 95% CI 0.78-0.99; I2 = 0%). There was no significant reduction in all-cause death in HFrEF (HR 0.95, 95% CI 0.83-1.09; I2 = 0%). In HFpEF, there were no improvements in Kansas City Cardiomyopathy Questionnaire clinical summary scores (mean difference 0.81, 95% CI -2.16-3.77; I2 = 72%) or 6-minute walk distance (mean difference 3.34 meters, 95% CI -7.86-14.54; I2 = 28%). There was no difference in all-cause mortality in HFpEF (HR 1.94, 95% CI 0.92-4.09; I2 = 0%). Overall, oral sGC stimulators had low medication-related serious adverse events. CONCLUSION: Oral sGC stimulators are well tolerated in HF and reduce the incidence of HF hospitalization but not cardiovascular death among patients with HFrEF. However, there are no apparent benefits in HFpEF.

Impact of targeted pulmonary arterial hypertension therapy in patients with combined post- and precapillary pulmonary hypertension.

BACKGROUND: Combined post- and precapillary pulmonary hypertension (CpcPH) portends poor outcomes in pulmonary hypertension related to left heart disease (PH-LHD). While recent evidence does not support the use of targeted pulmonary arterial hypertension (PAH) therapy in PH-LHD, there is a lack of clinical data on their use in CpcPH. We evaluated the outcomes in patients with CpcPH treated with PAH therapies. METHODS: Retrospectively, 50 patients meeting hemodynamic criteria of CpcPH and started on PAH-targeted drugs were identified. Fifty age- and gender-matched PAH patients were chosen as controls. We evaluated the change in 6-minute walk distance, World Health Organization functional class (FC), tricuspid annular plane systolic excursion, BNP or NT-proBNP, and pulmonary artery systolic pressure at 3, 6, 12, and 24 months of follow-up. RESULTS: After adjusting for age and gender, there was no improvement in World Health Organization FC in CpcPH over 2 years (odds ratio of change to FC I/II 1.01, 95% CI: 0.98-1.04). There was no significant improvement in 6-minute walk distance (ß coefficient 0.21, 95% CI: -0.98 to 1.4), reduction in BNP/NT-proBNP (ß coefficient -12.16, 95% CI: -30.68 to 6.37), increase in tricuspid annular plane systolic excursion (ß coefficient 0.074, 95% CI: 0.010-0.139), or decrease in pulmonary artery systolic pressure (0.996, 95% CI: 0.991-1.011) in CpcPH with therapy. There was higher mortality in CpcPH compared to PAH on treatment (24% vs 4%, P = .003). CONCLUSIONS: There were no improvements in symptoms, exercise capacity, or echocardiographic parameters with PAH-targeted therapy in CpcPH. Further studies into potential treatments benefiting this population are needed.

Factors associated with psychological distress for couples facing head and neck cancer: A systematic literature review.

OBJECTIVES: Cancer patients in supportive relationships display improved health and survival outcomes. Identifying factors that might respond to intervention for Head and Neck Cancer (HNC) dyads is important as HNC patients and their partners experience heightened distress. This article systematically reviewed and evaluated the research findings and methodological quality of studies which identified factors influencing psychological distress for couples facing HNC. METHODS: PsycINFO, Medline, and CINAHL were searched. Studies were included if they used validated psychological distress measures and quantitative data collection methods. Eleven studies satisfied inclusion criteria. RESULTS: Studies identified factors associated with the psychological distress experienced by couples facing HNC, with substantial effect size variation. These factors included clinical, sociodemographic, relational, and psychological variables. Factors associated with increased psychological distress included disease burden, reduced social contact, perception of reduced relationship quality, and less adaptive/assimilative coping although the effect sizes displayed considerable heterogeneity. Overall, studies possessed good methodological quality but generally could have been improved by minimising the risk of non-response bias and fully reporting relational characteristics. CONCLUSIONS: The implications of these results for clinical practice and future research are discussed. Further research is recommended to report effect sizes more consistently for both dyad members to gain greater insight into couple-level distress and to perform moderator analyses to identify which variables influence the magnitude of psychological distress.

An explanatory sequential investigation of the working alliance as a change process in videoconferencing psychotherapy.

OBJECTIVES AND DESIGN: Debate exists as to patient experience, and the importance, of the working alliance (WA) in videoconferencing psychotherapy (VCP). This study used a two-phase explanatory sequential design to investigate the WA as a change process in VCP. METHODS: Phase I: sessional VCP outcome and WA data were analysed using multilevel modelling (n = 46). Phase II: participants (n = 12) from Phase I were recruited to semi-structured interviews, analysed using thematic framework analysis. RESULTS AND CONCLUSIONS: Results demonstrate: (1) a significant correlation between WA and outcome (F(1, 15.19) = 25.01, p < 0.001), (2) previous session WA significantly predicted outcome in the next session (F(1, 355.61) = 4.47, p < 0.05), and (3) previous session outcome significantly predicted next session WA (F(1, 55.3) = 15.19, p < 0.001), with three core themes explaining patient experience (engaging with the medium, connection with the therapist, and working via the medium). Results are discussed and future research recommended.

Self-help Acceptance and Commitment Therapy for Carers of People with Multiple Sclerosis: A Feasibility Randomised Controlled Trial.

Acceptance and Commitment Therapy (ACT) is an established psychological therapy, but its effectiveness for carers of people with multiple sclerosis (MS) experiencing carer-related strain has not been established. This study assessed the acceptability and feasibility of conducting a randomised controlled trial comparing ACT self-help, telephone-supported ACT self-help, and usual care. We describe a mixed-method, parallel three-armed feasibility randomised controlled trial. Participants were carers (i.e. caregivers) of people with MS. The self-help group received an ACT self-help text (covered over 8 weeks), the enhanced self-help group additionally received weekly telephone support. All participants completed questionnaires at baseline, 3-month, and 6-month post-randomisation, assessing carer strain, health-related quality of life, and ACT-related processes. A sample of participants was also interviewed. Twenty-four carers were randomised. Participants found the study procedures to be acceptable, but highlighted difficulties with the self-help text and timing of the intervention. An exploratory, group-level analysis indicated effectiveness for the enhanced self-help group on carer strain (consistent across both follow-ups), with convergent qualitative reports to support this. A full trial of ACT-based, telephone-supported self-help is warranted, including both the self-help and enhanced self-help design, following significant adaptions to the self-help itself. An internal pilot would, therefore, be recommended to further assess the feasibility after changes are incorporated.Trial registration: The trial was registered on ClinicalTrials.gov (NCT03077971).

A brief acceptance and commitment intervention for work-related stress and burnout amongst frontline homelessness staff: A single case experimental design series.

PURPOSE: Recent intervention research for burnout amongst those working in health and social care contexts has found acceptance and commitment therapy (ACT) interventions to be of use but has provided less clarity on the role of psychological flexibility (a key ACT construct). This study further evaluated the usefulness of ACT for burnout and work-engagement and assessed the role of psychological flexibility in contributing to therapeutic change. PROCEDURE: A nonconcurrent multiple-baseline across-participants single-case experimental design was used. Four participants were recruited from a homelessness organization in the East Midlands, England. The ACT-intervention was split into three modules to reflect the three aspects of the ACT triflex, and the sequence of delivery was randomized for each participant in order to test the relationship between these aspects. FINDINGS: Support was found for the ACT intervention reducing exhaustion and increasing work-engagement. Psychological Flexibility increased in all participants and was temporally related to increases in other outcome variables in some instances. Delivery of the intervention focussed on any given aspect of the ACT triflex could increase different domains of psychological flexibility. IMPLICATIONS: This study adds to the growing body of research in favour of ACT interventions for burnout and adds to the understanding of psychological flexibility as a mediating variable.

Predicting outcomes and sudden gains from initial in-session interactions during remote cognitive-behavioural therapy for severe health anxiety.

There has been a dramatic increase in remote psychotherapy since the onset of the COVID-19 crisis. There is also expected to be an increase in mental health problems in the wake of the COVID-19 pandemic. An increase in severe health anxiety (SHA) is particularly anticipated, for which cognitive-behavioural therapy (CBT) is a frontline treatment. However, it is unclear what interaction types are associated with outcome-improvement in remote-CBT (rCBT) for SHA. This study aimed to identify interaction types that predict outcomes and sudden gains in rCBT for SHA using initial therapy session content. Forty-eight participants in rCBT for SHA had interactions at their first sessions categorized and rated in terms of patient activation: an individual's confidence and ability to manage their health. Multilevel modelling assessed whether early interaction types predicted session-by-session wellbeing. For participants experiencing sudden gains (n = 12) interactions at the session directly prior to the gain were similarly categorized and rated. The scores were then compared with ratings for the preceding session. A smaller proportion of early sessions was taken up with problem descriptions among those with greater outcome improvements. There was also a significant reduction in the proportion of the session spent describing problems in the session directly prior to a sudden gain, as compared with the previous session. Conversely, clients with better outcomes made more positive evaluations of themselves and therapy, noticed more positive changes and made more contributions to structuring interactions at initial sessions. Specific early interaction types predict session-by-session outcomes and precede sudden gains in rCBT for SHA.

Using smart-messaging to enhance mindfulness-based cognitive therapy for cancer patients: A mixed methods proof of concept evaluation.

OBJECTIVE: Depression and anxiety lead to reduced treatment adherence, poorer quality of life, and increased care costs amongst cancer patients. Mindfulness-based cognitive therapy (MBCT) is an effective treatment, but dropout reduces potential benefits. Smart-message reminders can prevent dropout and improve effectiveness. However, smart-messaging is untested for MBCT in cancer. This study evaluates smart-messaging to reduce dropout and improve effectiveness in MBCT for cancer patients with depression or anxiety. METHODS: Fifty-one cancer patients attending MBCT in a psycho-oncology service were offered a smart-messaging intervention, which reminded them of prescribed between-session activities. Thirty patients accepted smart-messaging and 21 did not. Assessments of depression and anxiety were taken at baseline, session-by-session, and one-month follow-up. Logistic regression and multilevel modelling compared the groups on treatment completion and clinical effectiveness. Fifteen post-treatment patient interviews explored smart-messaging use. RESULTS: The odds of programme completion were eight times greater for patients using smart-messaging compared with non-users, controlling for age, gender, baseline depression, and baseline anxiety (OR = 7.79, 95% CI 1.75 to 34.58, p = .007). Smart-messaging users also reported greater improvement in depression over the programme (B = -2.33, SEB = .78, p = .004) when controlling for baseline severity, change over time, age, and number of sessions attended. There was no difference between groups in anxiety improvement (B = -1.46, SEB = .86, p = .097). In interviews, smart-messaging was described as a motivating reminder and source of personal connection. CONCLUSIONS: Smart-messaging may be an easily integrated telehealth intervention to improve MBCT for cancer patients.

Behavioural activation treatment for depression in individuals with neurological conditions: a systematic review.

OBJECTIVE: To evaluate the effectiveness of behavioural activation interventions for people with neurological conditions with comorbid depression, and explore content and adaptations. DATA SOURCES: PsycINFO, MEDLINE, CINAHL, AMED, and EMBASE databases were searched on the 19 November 2019. Reference lists of selected full-texts were screened by title. REVIEW METHODS: We included peer-reviewed studies published in English that used behavioural activation for treatment of depression in adults with a neurological condition. Single-case reports, reviews, and grey literature were excluded. Methodological quality was assessed by two authors independently, and quality was appraised using Critical Appraisal Skills Programme checklists. RESULTS: From 2714 citations, 10 articles were included comprising 590 participants. Behavioural activation was used to treat depression in people with dementia (n = 4), stroke (n = 3), epilepsy (n = 1), Parkinson's disease (n = 1), and brain injury (n = 1). Sample size ranged from 4 to 105 participants. There were seven randomized controlled studies; however, no studies compared behavioural activation to an alternative psychological therapy. The effect sizes varied between small and large in the studies where effect size could be calculated (d = 0.24-1.7). Methodological quality of the included studies was variable. Intervention components were identifying and engaging in pleasurable activities, psychoeducation, and problem-solving. Adaptations included delivering sessions via telephone, delivering interventions via primary caregivers, and giving psychoeducation to caregivers. CONCLUSION: The effectiveness of behavioural activation in randomized controlled trials varied from small to large (d = 0.24-1.7) in reducing depression. The content of behavioural activation was comparable to established treatment manuals. Adaptations appeared to support individuals to engage in therapy. REVIEW REGISTRATION: PROSPERO 2018, CRD42018102604.

Preventing relapse with personalized smart-messaging after cognitive behavioural therapy: A proof-of-concept evaluation.

OBJECTIVES: Cognitive behavioural therapy (CBT) can improve symptoms of anxiety and depression, but also reduces the risk of future relapse after therapy completion. However, current CBT relapse prevention methods are resource-intensive and can be limited in clinical practice. This paper investigates a personalized means of reducing relapse using smart-messaging in two settings: research and routine care. DESIGN: Study 1 presents a cohort study comparing a cohort of smart-messaging users versus non-users. Study 2 presents time series follow-up data from a case series of smart-messaging users from clinical practice. METHODS: Fifteen of 56 CBT completers who participated in a trial for the treatment of health anxiety wrote advice they would want if in future they were doing well, experiencing early warning signs of relapse, or experiencing full relapse. Following CBT, participants received weekly text-message requests to rate their well-being. Dependent upon their response, participants received tailored advice they had written, appropriate to the well-being level reported after recovery from health anxiety. Smart-messaging was also trialled in a routine practice sample of 14 CBT completers with anxiety and depression. RESULTS: Across a 12-month follow-up, participants receiving smart-messaging showed greater health improvements than those who did not. Well-being scores showed stability between CBT completion and 6-month follow-up among routine care patients. CONCLUSIONS: These findings suggest that a low-intensity, personalized relapse prevention method can have a clinical benefit following CBT for common mental health problems. PRACTITIONER POINTS: Post-treatment outcomes may be improved using personalized smart-messaging to prevent relapse following cognitive behavioural therapy (CBT) for health anxiety. In clinical practice, post-treatment smart-messaging can be well-used by patients and may help maintain stable well-being in the 6 months after CBT ends. This evidence supports the clinical utility of a brief tailored digital intervention, which can be integrated within routine clinical practice with minimal therapist input. Overall, longer-term post-CBT outcomes may be improved by integrating a smart-messaging intervention at the end of therapy.

Reducing dropout in acceptance and commitment therapy, mindfulness-based cognitive therapy, and problem-solving therapy for chronic pain and cancer patients using motivational interviewing.

OBJECTIVE: Acceptance and commitment therapy, mindfulness-based cognitive therapy, and problem-solving therapy are types of cognitive-behavioural therapy (CBT) group that improve physical and mental health in chronic pain or cancer. However, dropout is high due to group demands alongside physical impairments. Motivational interviewing (MI) is a well-evidenced means of enhancing treatment adherence. Few studies have investigated MI as an adjunct to CBT in cancer or chronic pain, and none have established the minimum MI duration required for adherence improvement. This study evaluated minimal-duration MI to improve adherence in three CBT group types for cancer and chronic pain. METHODS: In a cohort study of 99 cancer and chronic pain patients, 47 were given a 10- to 15-min structured MI telephone intervention (MI-call) after the first session. The remaining 52 received a CBT group without MI (no-MI). RESULTS: Odds of completing group CBTs were five times greater for patients in the MI-call cohort versus no-MI. Effects remained when controlling for age, gender, diagnosis, group type, and baseline quality of life. The MI-call cohort attended one extra session per patient compared to no-MI, controlling for age, gender, and diagnosis. CONCLUSIONS: A brief MI telephone intervention may improve adherence to group CBTs in cancer and chronic pain. PRACTITIONER POINTS: A brief motivational interviewing (MI) telephone intervention may reduce dropout from group cognitive-behavioural therapies (CBTs) for cancer and chronic pain patients when administered after the first group session in routine care. Recipients of this intervention were five times more likely to complete a group CBT programme than those who did not receive it. Therefore, a minimal-dose MI intervention can have clinically important effects on dropout in group CBTs for patients with long-term conditions. It is unclear whether this intervention would also result in greater outcome improvements.

Factors influencing the transition experience of carers for persons with dementia, when the person with dementia moves into residential care: systematic review and meta-synthesis.

Aims: To understand factors influencing the experience of carers for people with dementia, when that person moves from living in the community to living in residential care. Specifically, we aimed to identify facilitators and inhibitors of carer adjustment during this transition.Method: A systematic search of CINAHL, EMBASE, PubMed, and PsycINFO databases was conducted. Nine qualitative articles published between 2001 and 2017, based on the experiences of 141 carers, were included. Thematic analysis was applied to the data, with the concepts of transition inhibitors and facilitators being used to structure the analytic process.Results: Analysis produced five themes, representing factors that could affect carer experiences of the focal transition-process: modifying the difficulty of this process according to their presence or absence. The themes were (1) Connection, pertaining to the carer feeling connected to the person with dementia and professionals during this transition; (2) Informed & Informing, relating to exchange of information between the carer and facility staff or health professionals; (3) The facility: welcoming & skilful, dealing with carer perceptions of the facility and their confidence in the staff; (4) It's What You Make of It, discussing the meaning the carer made of the admission and the impact this had; and (5) Sharing Responsibility, addressing how carers were affected by the perceived sharing of responsibility for care-provision.Conclusions: A supportive network has a significant role to play in facilitating this transition for carers. However, further research into what carers would find useful during this time is needed.

Patient activation in psychotherapy interactions: Developing and validating the consultation interactions coding scheme.

OBJECTIVE: We describe the development of an instrument aiming to offer interaction-level feedback based on "patient activation": client confidence and perceived ability to manage their health. METHOD: Twenty-two session-transcripts from cognitive behavioral therapy with high-users of healthcare were analyzed thematically, producing themes describing in-session interactions. Themes were subcategorized using patient activation theory into high and low activation presentations. Two coders new to the process were trained to use this consultation interactions coding scheme (CICS). Inter-rater reliability (IRR), convergent validity, and clinical utility were assessed and illustrated with extreme cases. RESULTS: Good-to-excellent IRR was achieved. The CICS, therapeutic alliance, and therapist competence were correlated. Client engagement in session-structuring interactions correlated with outcome. The highest CICS scorer showed multiple outcome-improvements, the lowest scorer reported deteriorations. CONCLUSIONS: This study presents the CICS's psychometric properties and indicates the value of client engagement in session-structuring.

Extending the use of routine outcome monitoring: Predicting long-term outcomes in cognitive behavioral therapy for severe health anxiety.

Objective: Routine outcome monitoring (ROM) is a well-evidenced means of improving psychotherapy's effectiveness. However, it is unclear how meaningful ROM is for problems that span physical and mental health, such as severe health anxiety. Physical and mental health comorbidities are common amongst severe health anxiety sufferers and cognitive behavioral therapy (CBT) is a recommended treatment. Method: Seventy-nine participants received CBT for severe health anxiety in a clinical trial. The Outcome Rating Scale (ORS: a ROM assessment of wellbeing) was completed at each session. Multilevel modeling assessed whether last-session ORS predicted health anxiety and other outcomes over 12-month follow-up. Similar models were developed using health anxiety as a comparative outcome-predictor. Outcome-improvements of treatment-responders with sudden gains were compared to those of non-sudden-gainers. Results: Last-session ORS scores predicted all outcomes up to 12 months later, with a comparable predictive effect to health anxiety. Sudden-gainers on the ORS reported significantly greater improvement in depression, functioning, and wellbeing, but no difference in health anxiety or other measures. Conclusion: The ORS may be a feasible, overall estimate of health, functioning, and quality of life in psychotherapy for severe health anxiety. Sudden gains on the ORS may be clinically meaningful with respect to some long-term outcomes.

How patients adjust psychologically to the experience of head and neck cancer: A grounded theory.

Numerous physical and psychological challenges are recognised as consequences of head and neck cancer and its treatment, but little is known about how patients adjust psychologically to these experiences. This study aimed to develop a theoretical understanding of the processes patients engage in when adjusting to head and neck cancer. Twelve patients participated in semi-structured interviews conducted individually and transcribed verbatim. Data were analysed using grounded theory methodology. Analysis generated a core category of "modifying my relationship to the changes cancer brings," which encompassed 11 processes patients engaged in throughout their adjustment: "survive mode," "instrumental support from others," "making a choice," "developing own understanding," "acceptance," "talking with others," "making changes," "redefining or regaining normality," "managing emotions/distressing thoughts," "putting things into perspective" and "barriers to progress." Contrasting findings are discussed, and a model of psychological adjustment to head and neck cancer is proposed. The study found that patients engage in a series of processes throughout adjustment to head and neck cancer, which broadly map on to the cancer treatment trajectory, though these processes did not appear to be specific to head and neck cancer. The proposed model may be used as a framework to guide psychological interventions.