A scoping review of non-pharmacological perinatal interventions impacting maternal sleep and maternal mental health.

BACKGROUND: A woman's vulnerability to sleep disruption and mood disturbance is heightened during the perinatal period and there is a strong bidirectional relationship between them. Both sleep disruption and mood disturbance can result in significant adverse outcomes for women and their infant. Thus, supporting and improving sleep in the perinatal period is not only an important outcome in and of itself, but also a pathway through which future mental health outcomes may be altered. METHODS: Using scoping review methodology, we investigated the nature, extent and characteristics of intervention studies conducted during the perinatal period (pregnancy to one-year post-birth) that reported on both maternal sleep and maternal mental health. Numerical and descriptive results are presented on the types of studies, settings, sample characteristics, intervention design (including timeframes, facilitation and delivery), sleep and mood measures and findings. RESULTS: Thirty-seven perinatal interventions were identified and further described according to their primary focus (psychological (n = 9), educational (n = 15), lifestyle (n = 10), chronotherapeutic (n = 3)). Most studies were conducted in developed Western countries and published in the last 9 years. The majority of study samples were women with existing sleep or mental health problems, and participants were predominantly well-educated, not socio-economically disadvantaged, in stable relationships, primiparous and of White race/ethnicity. Interventions were generally delivered across a relatively short period of time, in either the second trimester of pregnancy or the early postnatal period and used the Pittsburgh Sleep Quality Index (PSQI) to measure sleep and the Edinburgh Postnatal Depression Scale (EPDS) to measure mood. Retention rates were high (mean 89%) and where reported, interventions were well accepted by women. Cognitive Behavioural Therapies (CBT) and educational interventions were largely delivered by trained personnel in person, whereas other interventions were often self-delivered after initial explanation. CONCLUSIONS: Future perinatal interventions should consider spanning the perinatal period and using a stepped-care model. Women may be better supported by providing access to a range of information, services and treatment specific to their needs and maternal stage. The development of these interventions must involve and consider the needs of women experiencing disadvantage who are predominantly affected by poor sleep health and poor mental health.

Multiple dimensions of sleep are consistently associated with chronically elevated depressive symptoms from late pregnancy to 3 years postnatal in Indigenous and non-Indigenous New Zealand women.

INTRODUCTION: Poor sleep and depressive symptoms are common throughout the perinatal period, but little is known about the extended time course of depression and the sleep dimensions associated with these trajectories. OBJECTIVE: This study investigated different depression trajectories in New Zealand Maori and non-Maori women from late pregnancy to 3 years postnatal. Relationships between multiple dimensions of sleep and these depression trajectories were also investigated. METHODS: Data from 856 women (30.6% Maori and 69.4% non-Maori) from the longitudinal Moe Kura cohort study were used. Depressive symptoms and multiple dimensions of sleep (quality, duration, latency, continuity and daytime sleepiness) were collected at 36 weeks' gestation, 12 weeks postnatal and 3 years postnatal. Trajectory analysis was completed using latent class analysis. RESULTS: Latent class analysis revealed two distinct groups of depressive symptom trajectories: 'chronic high' and 'stable mild' for both Maori and non-Maori women. Maori women in both trajectories were more likely than non-Maori women to have clinically significant depressive symptoms at every time point. Poorer sleep quality, latency, continuity and greater daytime sleepiness were consistently associated with the chronic high depressive symptom trajectory at all three time points, after controlling for sociodemographic factors. CONCLUSION: A significant proportion of Maori and non-Maori women experience chronically high depressive symptoms during the perinatal period and the following years. Across this extended time frame, Maori women have a higher probability of experiencing clinically significant depressive symptoms compared to non-Maori women. These persistent patterns of depressive symptoms occur concurrently with multiple dimensions of poor sleep. Given the well-described impact of maternal depression on the mother, child, family and community, this highlights the importance of healthcare professionals asking about mothers' sleep quality, continuity, latency and daytime sleepiness as potential indicators of long-term mood outcomes.

Sleep HAPi: A Feasibility and Descriptive Analysis of an Early and Longitudinal Sleep Education Intervention for Pregnant Women.

Background: Poor sleep and prior depression are key predictors of perinatal depression, with research suggesting depressive symptoms may emerge in early pregnancy. Sleep is a potentially modifiable risk factor for depression. This pilot study examined the feasibility and acceptability of a six-month sleep education intervention designed to optimize sleep and minimize depressive symptoms throughout pregnancy. Sleep measures and depressive symptoms are described from 12 weeks gestation to 12 weeks postpartum.Participants: A community sample of nulliparous pregnant women with a history of depression were recruited prior to 14 weeks gestation.Methods: An individualized sleep education program was developed and participants engaged in three trimester specific sleep education sessions. Feasibility and acceptability were determined via recruitment and retention rates and participant feedback. Depressive symptoms and sleep were measured at five time points throughout the study.Results: 22 women enrolled in the study and 15 completed the intervention. Participants reported the intervention as highly acceptable. There was minimal change in all dimensions of sleep across pregnancy, but sleep measures were significantly worse at six weeks postpartum and improved by 12 weeks postpartum. Depressive symptoms were significantly lower at the conclusion of the intervention and 12 weeks postpartum compared to trimester 1.Conclusions: This sleep education program appears feasible, acceptable and may be effective in minimizing depressive symptoms in pregnant women with a history of depression. Trials with larger and more diverse samples are warranted and further studies to ascertain efficacy should be undertaken with a control group.

Long-term psychiatric inpatients' perspectives on weight gain, body satisfaction, diet and physical activity: a mixed methods study.

BACKGROUND: Obesity is a significant problem for people with serious mental illness. We aimed to consider body size from the perspective of long-stay psychiatric inpatients, focussing on: weight gain and its causes and impacts; diet and physical activity; and the perceived ability to make meaningful change in these domains. METHOD: A mixed methods study with 51 long-term psychiatric forensic and rehabilitation inpatients using semi-structured interviews combined with biometric and demographic data. RESULTS: 94% of participants were overweight or obese (mean BMI 35.3, SD 8.1). They were concerned about their weight, with 75% of them attempting to lose weight. Qualitative responses indicated low personal effectiveness and self-stigmatisation. Participants viewed their weight gain as something 'done to them' through medication, hospitalisation and leave restrictions. A prevailing theme was that institutional constraints made it difficult to live a healthy life (just the way the system is). Many had an external locus of control, viewing weight loss as desirable but unachievable, inhibited by environmental factors and requiring a quantum of motivation they found hard to muster. Despite this, participants were thoughtful and interested, had sound ideas for weight loss, and wished to be engaged in a shared endeavour to achieve better health outcomes. Consulting people as experts on their experiences, preferences, and goals may help develop new solutions, remove unidentified barriers, and improve motivation. CONCLUSIONS: The importance of an individualised, multifactorial approach in weight loss programmes for this group was clear. Patient-led ideas and co-design should be key principles in programme and environmental design.

The prevalence of symptoms of depression and anxiety, and the level of life stress and worry in New Zealand Maori and non-Maori women in late pregnancy.

OBJECTIVE: To describe the prevalence of symptoms of depression and anxiety, and the level of life stress and worry in late pregnancy for Maori and non-Maori women. METHODS: In late pregnancy, women completed a questionnaire recording their prior history of mood disorders; self-reported current depressive symptoms (⩾13 on the Edinburgh Postnatal Depression Scale), current anxiety symptoms (⩾6 on the anxiety items from the Edinburgh Postnatal Depression Scale), significant life stress (⩾2 items on life stress scale) and dysfunctional worry (>12 on the Brief Measure of Worry Scale). RESULTS: Data were obtained from 406 Maori women (mean age = 27.6 years, standard deviation=6.3 years) and 738 non-Maori women (mean age = 31.6 years, standard deviation=5.3 years). Depressive symptoms (22% vs 15%), anxiety symptoms (25% vs 20%), significant life stress (55% vs 30%) and a period of poor mood during the current pregnancy (18% vs 14%) were more prevalent for Maori than non-Maori women. Less than 50% of women who had experienced ⩾2 weeks of poor mood during the current pregnancy had sought help. Being young was an independent risk factor for depressive symptoms, significant life stress and dysfunctional worry. A prior history of depression was also consistently associated with a greater risk of negative affect in pregnancy. CONCLUSION: Antenatal mental health requires at least as much attention and resourcing as mental health in the postpartum period. Services need to specifically target Maori women, young women and women with a prior history of depression.

'Out of the frying pan': the challenges of prescribing for insomnia in psychiatric patients.

OBJECTIVES: Managing insomnia is a common challenge for psychiatrists and their patients. We have observed an increasing use of quetiapine as a hypnosedative. METHODS: We conducted an audit with the aim of establishing the prescribing patterns of local general psychiatrists in New Zealand, comparing them with established guidelines and determining the extent of the prescribing of quetiapine as a hypnosedative. Participant psychiatrists were recruited from peer review groups. Each participant provided anonymised prescribing information from 10 patients and noted their intention when prescribing. RESULTS: Twenty-five clinicians (58% response rate) responded with prescriptions for 100 in-patients and 177 community mental health patients. 60% of in-patients and 62% of community patients were prescribed medications to aid with sleep. The most commonly prescribed medications were zopiclone, quetiapine and benzodiazepines. Prescribing adhered with the recommended guidelines for 20% of benzodiazepine and 35% of zopiclone prescriptions. Two thirds (60%) of the community prescriptions for quetiapine were primarily for hypnosedation. CONCLUSIONS: There is little concordance between guidelines for hypnosedative prescribing and the practices of general psychiatrists. Less zopiclone and fewer benzodiazepines were prescribed than in other studies, while more quetiapine was prescribed. The 'off-label' use of quetiapine and the duration of zopiclone and benzodiazepine use are discussed.

Madness at the movies: prioritised movies for self-directed learning by medical students.

OBJECTIVE: We aimed to systematically compile a list of 10 movies to facilitate self-directed learning in psychiatry by medical students. METHOD: The selected areas were those of the top five mental health conditions from the Global Burden of Disease 2010 study. The search strategy for movies covered an extensive range of sources (published literature and websites), followed by closer examination and critical viewing of a sample. RESULTS: Out of a total of 503 potential movies that were identified, 23 were selected for viewing and more detailed critique. The final top 10 were: for depressive and anxiety disorders: Ordinary People (1980), Silver Linings Playbook (2012); for illicit drug use: Trainspotting (1996), Winter's Bone (2010), Rachel Getting Married (2008), Half Nelson (2006); for alcohol use disorders: Another Year (2010), Passion Fish (1992); and for schizophrenia: The Devil and Daniel Johnston (2006), and An Angel at My Table (1990). CONCLUSIONS: The final selection of 10 movies all appeared to have relatively high entertainment value together with rich content in terms of psychiatric themes. Further research could evaluate the extent to which medical students actually watch such movies, by assessing the level of withdrawals from a medical school library and surveying student responses.

Discovering stigma through recovery teaching.

OBJECTIVE: From the perspective of the tutor, course coordinators and a clinical supervisor, we describe and reflect on our observations of innovative service-user led tutorials on recovery that were delivered to final year medical students as part of their psychiatric module. CONCLUSIONS: Much to our surprise, and in contrast to observations elsewhere during the module, students openly expressed blatant stigmatising attitudes in the tutorials on recovery, particularly after spending time with inpatient services. More specifically, they were pessimistic about the possibility of recovery and they struggled to accept the service user status of the recovery tutor. This prompted us to reflect on what and how we teach psychiatry.

How well do medical students rate and communicate clinical empathy?

BACKGROUND: This article presents findings from a prospective, longitudinal cohort educational study investigating empathy communication in clinical consultations. It reports on changes in students' self-report empathy during medical undergraduate training, investigates how well peers can assess student competence in motivational interviewing/brief interventions (MI/BI) skills and explores the relationship between students' self-report empathy and peer- or tutor-assessments of competence. METHODS: 72 medical students completed the Jefferson Scale of Physician Empathy at three time points: at the beginning of their fifth year medical training (Time 1), after a specific MI/BI training session during their fifth year medical training (Time 2) and 1 year later during a revision session in year 6. Competence in BI/MI consultation was assessed using the validated tool Behaviour Change Counselling Index. RESULTS: A significant decline in medical students' empathy scores was observed from year 5 to year 6, consistent with international findings. Peer assessments and tutor ratings of competence in MI/BI skills performance were moderately correlated, but peer assessments were negatively correlated with medical students' self-rated empathy. Senior medical students who self-rated as more empathic received lower competence evaluations of MI/BI skills from their peers. Interventions to further investigate teaching and learning of empathy are discussed.

Sleep medication in acute psychiatric illness: patient's knowledge and prescription patterns in New Zealand.

Adult patients (N = 100) being treated for acute psychiatric illness were interviewed about their sleep problems and attitudes toward available treatments. Most (74%) were using at least one prescribed psychotropic drug with hypnotic or sedative effects. Participants prescribed three or more drugs were less likely to name them correctly compared with those prescribed less. One quarter (24%) did not know that they were on a hypnosedative; more than half of those not prescribed a hypnosedative thought they were. Most participants found their medication effective; however, 54% wished to discontinue it. Two fifths of zopiclone users had been using it for more than 12 months. Although subjective sleep problems are very common in this patient group, they have limited accurate knowledge about their medication treatments. Many want to try alternative nonpharmacological ways to manage their sleep problems.

Pathways to practice: overseas trained psychiatrists' experiences of the processes involved in commencing professional practice in Australasia.

OBJECTIVE: There are significant shortages in the psychiatric workforce in Australasia, particularly in the rural and remote regions of Australia and New Zealand. In response to these shortages, mental health services have recruited large numbers of overseas trained psychiatrists (OTP). These are specialist psychiatrists, trained and recognised as such in other countries. Our objective was to ascertain how OTPs experience the processes of commencing professional practice in Australasia. METHOD: OTPs were surveyed to identify the pathways to obtaining specialist registration and College Fellowship in Australasia and to explore their experiences as they engaged in this process. RESULTS: Although limited by a low response rate, the data does highlight a level of discontentment among those OTPs surveyed. The key issues identified related to the examination process, poor communication between different agencies (including the RANZCP), visa and residency related issues, medical board registration difficulties and notable differences between Australia and New Zealand. CONCLUSION: There is a negative perception among OTPs regarding the existing pathways to registration as specialist psychiatrists and the attainment of Fellowship. We submit that the RANZCP has a central and important role in resolving some of the underlying issues and supporting OTPs as vital and valued members of the workforce in Australia and New Zealand.

A randomised controlled trial of a probiotic and a prebiotic examining metabolic and mental health outcomes in adults with pre-diabetes.

AIMS: To evaluate the effect of the probiotic Lactobacillus rhamnosus HN001 and/or cereal enriched with oat-derived beta-glucan (OBG) on metabolic and mental health outcomes when administered to adults with pre-diabetes. DESIGN: 2×2 factorial design randomised, parallel-groups placebo-controlled; double-blinded for probiotic, single-blinded for cereals. PARTICIPANTS: Community-dwelling adults aged 18-80 years with pre-diabetes: glycated haemoglobin (HbA1c) 41-49 mmol/mol. INTERVENTIONS: Capsules containing Lactobacillus rhamnosus (HN001) (6×109 colony-forming units/day), or placebo capsules; and cereal containing 4 g/day OBG or calorie-matched control cereal, taken daily, for 6 months. Study groups were: (A) HN001 capsules+OBG cereal; (B) HN001 capsules+control cereal; (C) placebo capsules+OBG cereal and (D) placebo capsules+control cereal. OUTCOME MEASURES: Primary outcome: HbA1c at 6 months. SECONDARY OUTCOMES: fasting plasma glucose, fasting insulin, homeostatic model assessment of insulin resistance, fasting lipids, blood pressure, body weight, waist circumference, body mass index and mental well-being. RESULTS: 153 participants were randomised. There was complete HbA1c outcome data available for 129 participants. At 6 months the mean (SD) HbA1c was 45.9 (4.4) mmol/mol, n=66 for HN001, and 46.7 (4.3) mmol/mol, n=63 for placebo capsules; 46.5 (4.0) mmol/mol, n=67 for OBG and 46.0 (4.6) mmol/mol n=62 for control cereal. The estimated difference between HN001-placebo capsules was -0.83, 95% CI -1.93 to 0.27 mmol/mol, p=0.63, and between OBG-control cereals -0.17, 95% CI -1.28 to 0.94 mmol/mol, p=0.76. There was no significant interaction between treatments p=0.79. There were no differences between groups or significant interactions between treatments for any of the secondary outcomes. CONCLUSIONS: This study found no evidence of clinical benefit from the supplementation with either HN001 and/or cereal containing 4 g OBG on HbA1c and all secondary outcomes relevant to adults with pre-diabetes. TRIAL REGISTRATION NUMBER: Australian New Zealand Clincial Trials Registry number ACTRN12617000990325.

Uncertainty and certainty: perceptions and experiences of prediabetes in New Zealand primary care – a qualitative study.

Introduction Prediabetes is the asymptomatic precursor to type two diabetes mellitus, a significant and growing public health problem in New Zealand (NZ). Little is known about how general practitioners (GPs) and nurses view prediabetes care, and similarly little is known about how people with prediabetes view their condition and care. Aim This study aimed to investigate the views of NZ GPs and nurses, and people with prediabetes about prediabetes and its management. Methods This was a mixed qualitative methods study that is part of a randomised control trial of a prediabetes intervention. Results Three key themes emerged from the health professional data (GPs and nurses) and another three themes emerged from people with prediabetes data. GPs and nurses were uncertain about the progression of prediabetes; they felt prediabetes was not a priority and they were unsure about what to advise. People with prediabetes were uncertain about the diagnosis and information given to them; they were unsure about what to do about prediabetes and they found lifestyle change hard. Discussion GPs, nurses and people with prediabetes, expressed much uncertainty, but also some certainty about prediabetes. All were certain that prediabetes is common and increasing and that sustained lifestyle change was very difficult. But uncertainty prevailed about whether, in reality, prediabetes could be stopped, who would be most likely to benefit from lifestyle interventions and how best to achieve these. Older Maori and Pacific women were keen to promote lifestyle change and this appeared best done through Maori and Pacific peoples' organisations by means of co-designed interventions.

"Being-in-role": A teaching innovation to enhance empathic communication skills in medical students.

BACKGROUND: The communication of empathy is key in physician-patient interactions. We introduced drama training in "How to act-in-role" to medical students and evaluated the effect of this. METHODS: A quasi-experimental design was employed, with 72 students in the control and 77 students in the intervention group. The students' empathy scores were obtained using the Jefferson Scale of Physician Empathy (JSPE) during the introductory course. Both groups received tutorials in motivational interviewing and brief intervention skills. The students in the intervention group also received training in "How to act-in-role". The JSPE was repeated for both groups. The students subsequently undertook observed structured clinical examinations (OSCE). Both tutors and students evaluated the student's OSCE performance as well as their motivational interviewing skills using the Behavior Change Counseling Index (BECCI). RESULTS: Our findings show that while the students in both groups did not significantly differ in baseline empathy scores, the intervention group reported significantly higher empathy scores post-intervention. The intervention group also received significantly higher tutor ratings for their motivational interviewing (BECCI score) and overall OSCE performances. In conclusion, the teaching innovation "How to act-in-role" was effective not only in increasing medical students' self-reported empathy but also their competence in consultation skills.

A pilot longitudinal sleep education intervention from early pregnancy and its effect on optimizing sleep and minimizing depressive symptoms.

OBJECTIVES: Investigate the efficacy of a pilot longitudinal sleep education program for optimizing sleep and minimizing depressive symptoms in nulliparous pregnant women. DESIGN: Early and longitudinal sleep education intervention pilot study. SETTING: Community-based convenience sample of New Zealand women. PARTICIPANTS: 15 nulliparous women who were involved in a pilot of a longitudinal sleep education intervention during pregnancy (N = 15) were compared to a comparison group (n = 76) from another observational study with the same time points. Groups were matched on depression history and parity. INTERVENTION: A longitudinal sleep education program was developed. Women in the intervention group participated in three individualized and trimester specific education sessions designed to increase sleep knowledge and improve sleep practices. The comparison group received no sleep education. MEASUREMENTS: Self-reports of depressive symptoms and five dimensions of sleep (duration, quality, continuity, latency, daytime sleepiness) were compared between groups using linear mixed model analysis of variance. RESULTS: At the conclusion of the intervention, the intervention group had fewer depressive symptoms with none experiencing clinically significant depressive symptoms, while 21% of the comparison group were considered to have clinically significant depressive symptoms. The intervention group also had better sleep quality, sleep initiation and sleep continuity than the comparison group at late pregnancy. CONCLUSIONS: Findings suggest that a longitudinal sleep education intervention commencing early in pregnancy may be effective in optimizing sleep and minimizing depressive symptoms for nulliparous women with a history of depression. Further investigation of sleep education interventions to improve maternal mental health in pregnancy and postnatally is warranted.

Experiences of Weight-Loss Surgery in People With Serious Mental Illness: A Qualitative Study.

BACKGROUND: Bariatric surgery is seldom accessed by people with serious mental illness, despite high rates of obesity in this population. It is sometimes assumed that patients with complex psychiatric histories will have poor post-surgical weight loss or exacerbation of psychiatric symptoms, although this is unsubstantiated. OBJECTIVES: A qualitative descriptive study to explore personal experiences and the impact of bariatric surgery on physical and mental well-being and life-quality in individuals with serious mental illness. METHODS: Nine adults with a history of bariatric surgery and concurrent severe depressive disorder, bipolar disorder, or schizoaffective disorder were interviewed about their experiences of bariatric surgery and its outcomes using semi-structured interview schedules. Data were transcribed and inductive thematic analysis undertaken. RESULTS: Five broad themes emerged: (1) surgery was highly effective for weight loss, and resulted in subjective improvements in physical health, quality of life, and mental health described as being able to live a life; (2) recovering from surgery was a tough road, notably in the post-operative period where negative sequelae often anteceded benefits; (3) post-operative support was important, but sometimes insufficient, including from families, mental health services, and surgical teams; (4) most considered surgery life-changing, recommending it to others with mental illness and obesity, two had different experiences; (5) participants considered it discriminatory that people with mental illness were not referred or declined weight loss surgery. CONCLUSIONS: Participants benefited from bariatric surgery and felt it should be offered to others with mental illness, but with additional care and support.

Maternal sleep disturbances in late pregnancy and the association with emergency caesarean section: A prospective cohort study.

OBJECTIVES: To investigate the association between measures of sleep quality, sleep duration and sleep disorder symptoms in late pregnancy and likelihood of emergency caesarean section. DESIGN: Population-based prospective cohort study SETTING: New Zealand PARTICIPANTS: 310 Maori (Indigenous New Zealanders) and 629 non-Maori women MEASUREMENTS: Multivariable logistic regression models were used to investigate the association between type of delivery (emergency caesarean section vs. spontaneous vaginal delivery) and self-reported sleep duration, sleep quality and sleep-related symptoms, (e.g. snoring, breathing pauses during sleep, legs twitching/jerking) in the third trimester of pregnancy. Models were adjusted by ethnicity (ref=non-Maori), age (ref=16-19 y), parity (ref=nulliparous), clinical indicators (any vs. none), area deprivation (ref=least deprived quintile), BMI and for some models smoking. RESULTS: Women who reported poor quality sleep as measured by the General Sleep Disturbance Scale in later pregnancy had almost twice the odds of delivering via emergency caesarean than women with good sleep quality (OR=1.98, 95% CI 1.18-3.31). Reporting current breathing pauses during sleep (OR=3.27, 95% CI 1.38-7.74) or current snoring (OR=1.65, 95% CI 1.00-2.72) were also independently associated with a higher likelihood of an emergency caesarean. Short sleep duration and leg twitching/jerking were not independently associated with emergency caesarean section in this study. CONCLUSIONS: Supporting healthy sleep during pregnancy could be a novel intervention to reduce the risks associated with emergency caesarean section. Research on the effectiveness of sleep interventions for reducing caesarean section risk is required.

Food 4 Health - He Oranga Kai: Assessing the efficacy, acceptability and economic implications of Lactobacillus rhamnosus HN001 and ß-glucan to improve glycated haemoglobin, metabolic health, and general well-being in adults with pre-diabetes: study protocol for a 2 × 2 factorial design, parallel group, placebo-controlled randomized controlled trial, with embedded qualitative study and economic analysis.

BACKGROUND: The rates of pre-diabetes and type 2 diabetes mellitus are increasing worldwide, producing significant burdens for individuals, families, and healthcare systems. In New Zealand, type 2 diabetes mellitus and pre-diabetes disproportionally affect Maori, Pacific, and South Asian peoples. This research evaluates the efficacy, acceptability, and economic impact of a probiotic capsule and a prebiotic cereal intervention in adults with pre-diabetes on metabolic and mental health and well-being outcomes. METHODS: Eligible adults (n = 152) aged 18-80 years with pre-diabetes (glycated haemoglobin 41-49 mmol/mol) will be enrolled in a 2 × 2 factorial design, randomised, parallel-group, placebo-controlled trial. Computer-generated block randomization will be performed independently. Interventions are capsulated Lactobacillus rhamnosus HN001 (6 × 109 colony-forming units/day) (A) and cereal containing 4 g ß-glucan (B), placebo capsules (O1), and calorie-matched control cereal (O2). Eligible participants will receive 6 months intervention in the following groups: AB, AO1, BO2, and O1O2. The primary outcome is glycated haemoglobin after 6 months. Follow-up at 9 months will assess the durability of response. Secondary outcomes are glycated haemoglobin after 3 and 9 months, fasting glucose, insulin resistance, blood pressure, body weight, body mass index, and blood lipid levels. General well-being and quality of life will be measured by the Short-Form Health Survey 36 and Depression Anxiety Stress Scale 21 at 6 and 9 months. Outcome assessors will be blind to capsule allocation. An accompanying qualitative study will include 24 face-to-face semistructured interviews with an ethnically balanced sample from the ß-glucan arms at 2 months, participant focus groups at 6 months, and three health professional focus groups. These will explore how interventions are adopted, their acceptability, and elicit factors that may support the uptake of interventions. A simulation model of the pre-diabetic New Zealand population will be used to estimate the likely impact in quality-adjusted life years and health system costs of the interventions if rolled out in New Zealand. DISCUSSION: This study will examine the efficacy of interventions in a population with pre-diabetes. Qualitative components provide rich description of views on the interventions. When combined with the economic analysis, the study will provide insights into how to translate the interventions into practice. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12617000990325. Prospectively registered on 10 July 2017.

Challenging some assumptions about empathy.

BACKGROUND: In New Zealand little nursing or medical curricula time, if any, is specifically devoted to the enhancement of empathy. If being empathic is important in the context of patient care, it is a quality that is already present in students or is learned by students during their practicum in the company of experienced clinicians. This study aimed to compare self-reported empathy ratings between different groups of medical students and one cohort of nursing students who were either exposed or not exposed to explicit empathy training or learning in clinical settings in the presence of patients. METHODS: The Jefferson Scale of Physician Empathy (JSPE) was completed before and after groups of medical and nursing students had been exposed to various extended periods of practicum. Some medical student cohorts undertook brief empathy training, whereas others had no exposure. The nursing student cohort had no formal, explicit empathy training. RESULTS: Irrespective of profession, length of practicum or exposure to specific empathy training, there were no significant differences in the self-reported JSPE scores across the seven different cohorts of students. Empathy is a quality that is already present in students or is learned by students during their practicum DISCUSSION: If empathy is caught rather than taught, then brief efforts to enhance empathy may be futile. To optimise the inherent empathic qualities of aspirant health professionals, explicit consideration should be given to how empathy is influenced by the practicum experience.

The Porirua Protocol in the Treatment of Clozapine-Induced Gastrointestinal Hypomotility and Constipation: A Pre- and Post-Treatment Study.

BACKGROUND: Clozapine, an antipsychotic used in treatment-resistant schizophrenia, causes slow gastrointestinal transit in 50-80% of patients. Clozapine-induced gastrointestinal hypomotility is both common and serious, and potential complications include severe constipation, ileus, bowel obstruction and related complications, with a higher mortality rate than clozapine-related agranulocytosis. Little evidence exists on its prevention and management. METHOD: Using a well-validated radiopaque marker ('Metcalf') method, we compared colonic transit times (CTTs) of clozapine-treated inpatients not receiving laxatives with their transit times when receiving laxatives, with treatment prescribed according to the Porirua Protocol for clozapine-related constipation (docusate and senna augmented by macrogol 3350 in treatment-resistant cases). RESULTS: The median age of participants was 35 years, and median clozapine dose, plasma level and duration of treatment were 575 mg/day, 506 ng/mL and 2.5 years, respectively. Overall, 14 participants (10 male) were enrolled and all completed the study. Transit times improved markedly with laxative treatment. Median colonic transit without laxatives was 110 h (95% confidence interval [CI] 76-144 h), over four times longer than normative values (p < 0.0001). Median CTT with laxatives was 62 h (95% CI 27-96 h), a 2-day reduction in average transit time (p = 0.009). The prevalence of gastrointestinal hypomotility decreased from 86% pre-treatment to 50% post-treatment (p = 0.061). Severe gastrointestinal hypomotility decreased from 64 to 21% (p = 0.031). Subjective reporting of constipation did not correlate well with objective hypomotility, and did not change significantly with treatment. CONCLUSION: Treating clozapine-treated patients with docusate and senna augmented by macrogol appears effective in reducing CTTs in clozapine-induced constipation. Randomised controlled trials are the next step. Australian New Zealand Clinical Trial Registry ACTRN12616001405404 (registered retrospectively).