Acceptability of a technology-supported and solution-focused intervention (DIALOG+) for chronic depression: views of service users and clinicians.

BACKGROUND: Treating chronic depression represents a significant burden for the NHS, yet there is a lack of evidence-based interventions and research specifically focused on this condition. DIALOG+, a technology-assisted and resource-oriented intervention found effective for people with psychosis, may improve care for this service user group. The aim of this study was to explore the acceptability and relevance of DIALOG+ for the treatment of chronic depression in community-based settings. METHODS: A convenience sample of 16 mental health professionals and 29 service users with chronic depression tested the DIALOG+ intervention in routine community care appointments for 3 months across 3 different mental health NHS Trusts in England. Of these, 15 clinicians and 19 service users were individually interviewed about their experiences. Interview transcripts were analysed using thematic analysis by an analytic team which included a service user researcher. RESULTS: Analysis of the combined dataset identified five overarching themes: DIALOG+ Structure; Therapeutic Communication; Reflecting and Monitoring; Empowerment and Powerlessness; and The Impact of Technology. Overall, service users and clinicians were interested in the continued use of DIALOG+ as part of routine care. CONCLUSIONS: DIALOG+ was viewed as acceptable by both service users with chronic depression and their clinicians who work in community care settings, albeit with some caveats. Clinician training required significant improvements to address the issues that were referenced, most notably around support with using technology.

Acceptance and commitment therapy for adults with advanced cancer (CanACT): A feasibility randomised controlled trial.

OBJECTIVE: To understand the feasibility of recruiting people with advanced cancer into a randomised controlled trial of acceptance and commitment therapy (ACT) vs a standardised talking control (TC) and delivering ACT to this population; to explore the acceptability of outcome measures and generate normative data. METHODS: This was a feasibility two-arm randomised controlled trial. Participants were attendees with advanced cancer at one of three hospice-based day-therapy units in London, United Kingdom, who demonstrated low scores on the Functional Assessment of Cancer Therapies-General (FACT-G). The primary end point was 3 months. RESULTS: The recruitment target was 54 participants; 42 people were recruited and randomised to up to eight individual sessions of ACT (n = 20) or TC (n = 22). Eighteen out of 42 (43%) of participants completed the primary outcome at 3 months, and at least one follow-up was available in 30/42 (71%) participants. An exploratory analysis revealed a non-significant adjusted mean difference after 3 months in the main outcome FACT-G of -3.41 (CI = -18.61-11.79) with TC having better functioning. Over 6 months, the adjusted mean difference between trial arms was 2.25 (CI = -6.03-10.52) in favour of ACT. CONCLUSIONS: It is feasible to recruit people with advanced cancer in a trial of ACT versus TC. Future research should test the effectiveness of ACT in a fully powered trial.

Comparison of subjective quality of life domains in schizophrenia, mood, and anxiety disorders; an individual patient data meta-analysis.

This study sought to compare satisfaction with different subjective quality of life domains across individuals with three different mental health disorders. Samples from four separate studies were combined to conduct a one-step individual patient data meta-analysis. 5329 individuals with either a schizophrenia (n = 1839), mood (n = 1650), or anxiety disorder (n = 1840) were included. Mean satisfaction ratings for each life domain were compared across disorders. Associations between satisfaction ratings and personal characteristics were investigated using multivariable mixed effect models. Results showed that individuals with an anxiety disorder had the widest range of scores and reported lower satisfaction in most domains compared to those with a schizophrenia or mood disorder. Individuals with a schizophrenia disorder rated domains to do with 'others', such as relationships with family and sex life, as lower than individuals with a mood or anxiety disorder. Satisfaction ratings were often more impacted by personal characteristics, such as employment status, than by diagnostic category. These results demonstrate that specific life areas are impacted differently in the three mental health disorders studied. However, further research needs to consider the impact of personal characteristics across disorders, and the subjective quality of life in individuals with anxiety disorders in particular warrants further investigation.

Eliciting perspectives on remote healthcare delivery from service users with psychosis in the community: a cross-sectional survey study.

Introduction: The transition towards remote healthcare has been rapidly accelerated in recent years due to a number of factors, including the COVID-19 pandemic, however, few studies have explored service users' views of remote mental healthcare, particularly in community mental health settings. Methods: As part of a larger study concerned with the development of a remotely delivered psychosocial intervention, a survey was conducted with service users with psychosis (N = 200) from six NHS trusts across England to gain cross-sectional data about service users' opinions and attitudes towards remote interventions and explore how digital access varies across different demographic groups and geographical localities. Results: The majority of service users had access to technological devices and a quiet space to receive care. Age was a key factor in motivation to engage with remote care as older participants had less access to technological devices and the internet, and reported less confidence to learn how to use new technologies compared to younger participants. Differences in access and attitudes towards remote care were found across the different geographical localities. Over half of the participants (53.1%) preferred a hybrid model (i.e., mixture of face-to-face and remotely delivered treatment), with only 4.5% preferring remote treatment exclusively. Factors that both encourage and deter service users from engaging with remote care were identified. Conclusions: The findings of this study provide important information about the environmental and clinical barriers that prevent, or limit, the uptake of remotely delivered care for people with psychotic disorders. Although service users often have the ability and capacity to receive remote care, providers need to be cognisant of factors which may exacerbate digital exclusion and negatively impact the therapeutic alliance.

Medical undergraduates' use of behaviour change talk: the example of facilitating weight management.

BACKGROUND: Obesity, an increasing problem worldwide, is a leading cause of morbidity and mortality. Management principally requires lifestyle (i.e. behavioural) changes. An evidence-base exists of behaviour change techniques for weight loss; however, in routine practice doctors are often unsure about effective treatments and commonly use theoretically-unfounded communication strategies (e.g. information-giving). It is not known if communication skills teaching during undergraduate training adequately prepares future doctors to engage in effective behaviour change talk with patients. The aim of the study was to examine which behaviour change techniques medical undergraduates use to facilitate lifestyle adjustments in obese patients. METHODS: Forty-eight medical trainees in their clinical years of a UK medical school conducted two simulated consultations each. Both consultations involved an obese patient scenario where weight loss was indicated. Use of simulated patients (SPs) ensured standardisation of key variables (e.g. barriers to behaviour change). Presentation of scenario order was counterbalanced. Following each consultation, students assessed the techniques they perceived themselves to have used. SPs rated the extent to which they intended to make behavioural changes and why. Anonymised transcripts of the audiotaped consultations were coded by independent assessors, blind to student and SP ratings, using a validated behaviour change taxonomy. RESULTS: Students reported using a wide range of evidence-based techniques. In contrast, codings of observed communication behaviours were limited. SPs behavioural intention varied and a range of helpful elements of student's communication were revealed. CONCLUSIONS: Current skills-based communication programmes do not adequately prepare future doctors for the growing task of facilitating weight management. Students are able to generalise some communication skills to these encounters, but are over confident and have limited ability to use evidence-based theoretically informed techniques. They recognise this as a learning need. Educators will need to tackle the challenges of integrating theoretically informed and evidence based behaviour change talk within medical training.

Solution-focused approaches in adult mental health research: A conceptual literature review and narrative synthesis.

Solution-focused approaches are one approach to treatment used in a wide variety of settings in modern mental healthcare services. As yet, there has been no overall synthesis of how this approach is understood in the adult mental health literature. This conceptual review aimed to synthesize the ways that solution-focused approaches have been conceptualized and understood, within the adult mental health literature, in the five decades since their conception. A systematic search followed by multiple techniques from the narrative synthesis approach were used to develop a conceptual framework of the extracted data. Fifty-six papers published between 1993 and 2019 were included in the review. These papers spanned a variety of clinical contexts and countries, but despite this the underlying key principles and concepts of solution-focused approaches were remarkably similar over time and setting. Thematic analysis of extracted data outlined five key themes relevant to the conceptualization of this approach. This conceptual framework will help support clinicians using solution-focused techniques or therapies by giving them a coherent understanding of such approaches, by what mechanisms they work, and how key principles of this approach can be utilized in adult mental health settings.

Which life domains are people with major depression satisfied or dissatisfied with? An individual patient data meta-analysis.

BACKGROUND: People with depression tend to score low on measures of subjective quality of life (SQoL) which has been suggested to reflect a general negative bias of perception. However, studies do not tend to investigate specific life domains. This study investigated satisfaction with life domains in people with major depression and explored influential factors. METHODS: A one-step individual patient data meta-analysis combined data of 1710 people with major depression from four studies. In all studies, SQoL was measured on the Manchester Short Assessment of Quality of Life, which provides satisfaction ratings with 12 life domains. Associations between individual characteristics and satisfaction ratings were investigated using univariable and multivariable models. RESULTS: Mean satisfaction ratings varied across life domains. Participants expressed dissatisfaction with several domains but expressed satisfaction with others, mainly for domains associated with close relationships. Some of the investigated characteristics were consistently associated with satisfaction ratings across the domains. LIMITATIONS: The primary limitation of this study was in the analysis of individual characteristics, which were chosen based on identification in existing literature and availability in our datasets, and of which several were dichotomised to have sufficiently large numbers which may have resulted in lost nuance in the results. CONCLUSIONS: People with major depression distinguish between their satisfaction with different life domains and are particularly satisfied with their close relationships. This challenges the notion of a general negative appraisal of life in this group, and highlights the need to evaluate satisfaction with different life domains separately.

Clinical- and cost-effectiveness of a technology-supported and solution-focused intervention (DIALOG+) in treatment of patients with chronic depression-study protocol for a multi-site, cluster randomised controlled trial [TACK].

BACKGROUND: Many with an acute depressive disorder go on to develop chronic depression, despite ongoing care. There are few specifically designed interventions to treat chronic depression. DIALOG+, a technology-assisted intervention based on the principles of solution-focused therapy, may be beneficial. It has been shown to be effective as a treatment for patients with psychotic disorders, especially in regards to increasing quality of life. DIALOG+ was designed to be flexibly applied and not diagnosis-specific, aiming to structure communication and generate a personally-tailored care plan. This cluster randomised controlled trial (RCT) is part of a programme of research to adapt and test DIALOG+ for patients with chronic depression. METHODS: Patients will be eligible for the trial, if they have exhibited symptoms of depression or non-psychotic low mood for at least 2 years, have regular contact with a clinician and have a low subjective quality of life and moderate depressive symptoms. Clinicians, who routinely see eligible patients, will be recruited from a number of sites across NHS England. Clusters will have between 1 and 6 patients per clinician and will be randomised in a 1:1 ratio to either the intervention (DIALOG+) or active control group (treatment as usual + DIALOG scale). Clinicians in the intervention group are trained and asked to deliver the intervention regularly for 12 months. Active control participants receive treatment as usual and are asked to rate their satisfaction with areas of life and treatment on the DIALOG scale at the end of the clinical session. Approximately 112 clinician clusters will be recruited to reach a total patient sample size of 376. Clinical and social outcomes including costs are assessed at baseline and 3, 6 and 12 months post randomisation. The primary outcome will be subjective quality of life at 12 months. DISCUSSION: This definitive multi-site, cluster RCT aims to evaluate the clinical- and cost-effectiveness of DIALOG+ for people with chronic depression. If shown to be effective for this patient population it could be used to improve outcomes of mental health care on a larger scale, ensuring that patients with complex and co-morbid diagnoses can benefit. TRIAL REGISTRATION: ISRCTN11301686 . Registered on 13 Jun 2019.

Understanding Identity Changes in Psychosis: A Systematic Review and Narrative Synthesis.

BACKGROUND AND OBJECTIVE: Experiencing psychosis can be associated with changes in how people see themselves as individuals and in relation to others (ie, changes in their identity). However, identity changes receive little attention in treatment, possibly due to a lack of clarity or consensus around what identity change means in people with psychosis. We aimed to create a conceptual framework synthesizing how identity changes are understood in the psychosis literature. METHODS: Electronic databases were searched up to April 2020. Studies about identity changes among people with psychotic disorders were analyzed using narrative synthesis by a collaborative review team, including researchers from different disciplines, clinicians, and people who have experienced psychosis. RESULTS: Of 10 389 studies screened, 59 were eligible. Identity changes are understood in 5 ways as (1) characteristics of psychosis, (2) consequences of altered cognitive functioning, (3) consequences of internalized stigma, (4) consequences of lost roles and relationships, and (5) reflections of personal growth. These 5 understandings are not mutually exclusive. Across a heterogeneous literature, identity changes were mostly framed in terms of loss. CONCLUSIONS: Our conceptual framework, comprising 5 understandings, highlights the complexity of studying identity changes and suggests important implications for practice and research. For clinicians, this framework can inform new therapeutic approaches where the experience and impact of identity changes are acknowledged and addressed as part of treatment. For researchers, the conceptual framework offers a way of locating their understandings of identity changes when undertaking research in this area.

Why do psychiatric patients attend or not attend treatment groups in the community: A qualitative study.

BACKGROUND: Non-attendance of treatment groups in the community has been a long-standing problem in mental health care. It has been found to have financial ramifications for services, worsen outcomes for those that do not attend and negatively impact on therapeutic group processes. There is a need to gain a better understanding of patients' reasons for attending or not attending. This study aimed to explore patient views on facilitators and barriers to the attendance of treatment groups in the community. METHODS: The study used interview data collected as part of three studies that investigated treatment groups for psychiatric patients in the community. Sixty-seven interview transcripts were analysed using the framework method. RESULTS: Five themes relating to facilitators of group attendance were identified: opportunity for autonomy; self-acknowledging need and therapist encouragement; optimal group format and safe environment; interest in content and enjoyment; actual and expected benefits of attendance. Four themes related to barriers: not being sufficiently informed; concerns about social interactions and the unknown; limited accessibility; and negative group dynamics. CONCLUSION: To facilitate attendance and reduce attrition to treatment groups in the community clinicians should address patient's wishes for information, capture their interest in the group modality, and potentially offer a 'trial' session. Furthermore, they should make the group location and time as accessible as possible and create a moderately sized group of six to eight patients. In these groups, mutual respect, feelings of safety and encouragement appear essential to make patients feel they can benefit from attendance.

Pregnancy rates after transfer of cryopreserved blastocysts cultured in a sequential media.

OBJECTIVE: This study was undertaken to determine the pregnancy rate after transfer of cryopreserved blastocysts. STUDY DESIGN: Retrospective review of 61 patients from January 1, 2002, to December 31, 2003, who were transferred with blastocyst embryos cryopreserved on day 5 or 6 after culture in a sequential media. The cryopreserved blastocysts were thawed by using a 7-step dilution process after rapid thawing half hour to 2 hours before embryo transfer. RESULTS: The pregnancy rate after transfer of 61 patients with cryopreserved blastocysts was 66%, with 49% having cardiac activity. The pregnancy rate after transfer of 3 blastocysts was 71% and after transfer of 2 blastocysts was 66%. The pregnancy rate of blastocysts cryopreserved after intracytoplasmic sperm injection was 56%. CONCLUSION: Cryopreservation and transfer of blastocysts appears to be a reliable procedure, and that the human blastocyst can be cryopreserved and thawed without a significant loss of viability.