Epidemiology of International Match Injuries in Scottish Rugby: A Prospective Cohort Study.

Fifteen-a-side rugby union ("rugby") is a full-contact sport played separately by men and women, with large injury incidences reported previously. Context specific injury surveillance fulfils governing bodies' duty of care to understand risks to player welfare, yet no contemporary match injury epidemiology studies exist for international players in Scotland. The current study therefore aimed to describe the incidence, severity, burden and nature of match injuries sustained by Scotland's men's and women's national teams. A prospective cohort study of injuries recorded in matches across the 2017/18 and 2018/19 seasons was undertaken, with injury and exposure definitions in line with the international consensus for injury surveillance in rugby. Injury incidence was 120.0 (men) and 166.7/1,000 player match hours (women), injury severity was 12.0 (median) and 31.2 days (mean) for men, and 11.0 (median) and 30.2 days (mean) for women. Injury burden was 3,745 (men) and 5,040 days absence/1,000 player match hours (women). Concussion was the most common specific injury for men (22.5/1,000 hours) and women (26.7/1,000 hours). No statistical differences were found for incidence or severity measures between sexes. Injury incidence was greater than recent Rugby World Cup studies. High incidences of concussion reinforces the need for prevention strategies targeting this injury.

Neurodegenerative disease risk among former international rugby union players.

BACKGROUND: Autopsy studies of former contact sports athletes, including soccer and rugby players, frequently report chronic traumatic encephalopathy, a neurodegenerative pathology associated with traumatic brain injury. Nevertheless, little is known about the risk of neurodegenerative disease in these populations. We hypothesised that neurodegenerative disease risk would be higher among former elite rugby union players than the general population. METHODS: We conducted a retrospective cohort study accessing national electronic records on death certification, hospital admissions and dispensed prescriptions for a cohort of 412 male Scottish former international rugby union players and 1236 members of the general population, matched to former players by age, sex and area socioeconomic status. Mortality and incident neurodegenerative disease diagnoses among former rugby players were then compared with the matched comparison group. RESULTS: Over a median 32 years follow-up from study entry at age 30 years, 121 (29.4%) former rugby players and 381 (30.8%) of the matched comparison group died. All-cause mortality was lower among former rugby players until 70 years of age with no difference thereafter. During follow-up, 47 (11.4%) former rugby players and 67 (5.4%) of the comparison group were diagnosed with incident neurodegenerative disease (HR 2.67, 95% CI 1.67 to 4.27, p<0.001). CONCLUSIONS: This study adds to our understanding of the association between contact sports participation and the risk of neurodegenerative disease. While further research exploring this interaction is required, in the meantime strategies to reduce exposure to head impacts and head injuries in sport should be promoted.

The Overdose Crisis and Using Alone: Perspectives of People Who Use Drugs in Rural and Semi-Urban Areas of British Columbia.

Background: A significant rise in the rate of overdose deaths in British Columbia (BC), driven by fentanyl contamination of the illicit drug supply, led to the declaration of a public health emergency in 2016. Those at greatest risk of death are people who use alone. This community-based participatory action research study based in the Fraser East region of BC study aimed to overview underlying factors that contribute to unwitnessed overdoses in semi-urban and rural settings. Methods: This descriptive study used a community-based participatory action research model with peer research associates (PRAs) involved at various research stages. In total, 22 interviews were conducted with participants aged 19 and over who used illicit drugs in the Fraser East since the start of the public health emergency in 2016. A collaborative data analysis approach was taken for data interpretation, and content analysis was performed to explore themes surrounding using alone. Results: Among people who use drugs (PWUD), using alone was found to be influenced by (a) the availability of drugs and personal funds, (b) personal safety, (c) stigma and shame, (d) protecting privacy, (e) mental health conditions and addiction, and (f) the lack of engagement with harm reduction services. At times, using alone was due to unforeseen, episode-specific situations. Conclusion: A multi-dimentional and context-specific approach is needed in overdose prevention and response for people who use drugs alone. There is need for enhanced approaches that address or include support services for families to reduce stigma and isolation of those at risk of an overdose.

Substance use and overdose risk: documenting the perspectives of formerly incarcerated persons in the Fraser East region of BC.

BACKGROUND: The relationship between incarceration and risk of overdose has been well-documented in the literature, but few studies document the perspectives of persons at risk of overdose who were incarcerated. This sub-inquiry aimed to understand the experiences of persons with a history of substance use and incarceration in the Fraser East region of BC and how involvement with the criminal justice system affected their drug use and perceived risk of overdose. METHODS: The Fraser East Overdose Response project utilized a community-based participatory action approach that included peer researchers with lived experience in all parts of the research process. This qualitative pilot study aimed to better understand individuals at risk of an unwitnessed overdose in order to prevent deaths and identify effective local responses. A snowball sampling technique was used to recruit persons aged 19 and over who used illicit drugs over the past 3 years in the Fraser East since 2016. In total, 22 participants were interviewed. Of these, 13 participants identified a history of incarceration. Interviews were analyzed using a framework analysis approach. RESULTS: The perspectives that participants shared revealed that impacts from incarceration are influenced by policies but also highly individualized. Our inquiry found three broader themes, within which were situated differing and sometimes conflicting interpretations and experiences of systemic environments: (1) incarceration was associated with harms and was perceived to increase risk of overdose following release, (2) incarceration was perceived to have limited impact on substance use and overdose risk, and (3) incarceration was associated with a perceived reduction of substance use and overdose risk. CONCLUSIONS: Understanding the complexities of the perceptions of those with lived experience of substance use and incarceration is of importance to better inform interventions in this population. The existing knowledge base urgently requires further inquiry into the intersections between qualitative perspectives, environments and policies, and quantitative outcomes of overdose vís-a-vís correctional institution.

Automated Processing and Phenotype Extraction of Ovine Medical Images Using a Combined Generative Adversarial Network and Computer Vision Pipeline.

The speed and accuracy of phenotype detection from medical images are some of the most important qualities needed for any informed and timely response such as early detection of cancer or detection of desirable phenotypes for animal breeding. To improve both these qualities, the world is leveraging artificial intelligence and machine learning against this challenge. Most recently, deep learning has successfully been applied to the medical field to improve detection accuracies and speed for conditions including cancer and COVID-19. In this study, we applied deep neural networks, in the form of a generative adversarial network (GAN), to perform image-to-image processing steps needed for ovine phenotype analysis from CT scans of sheep. Key phenotypes such as gigot geometry and tissue distribution were determined using a computer vision (CV) pipeline. The results of the image processing using a trained GAN are strikingly similar (a similarity index of 98%) when used on unseen test images. The combined GAN-CV pipeline was able to process and determine the phenotypes at a speed of 0.11 s per medical image compared to approximately 30 min for manual processing. We hope this pipeline represents the first step towards automated phenotype extraction for ovine genetic breeding programmes.

Process Makes Perfect: Perceptions of Effectiveness in Collaborative Environmental Governance.

In evaluating effectiveness for collaborative environmental governance arrangements, a key concern is describing not just the processes and actors that are a part of these systems, but also the impacts that these processes have on ecological and social conditions. Existing research delineates an emphasis on process variables over outcome variables, as well as the difficulties of demonstrating causal relationships between collaborative governance processes and ecological outcomes. In this paper, we examined how process and outcome criteria are used by sponsors, industry practitioners, and participants of collaborative environmental governance (CEG) arrangements in Canada's forest sector to ascertain effectiveness. We explicitly sought evidence from sponsors and industry practitioners of self-described effective forest advisory committees, anticipating that sponsors or practitioners might place greater emphasis than participants on outcome criteria over process criteria. We analyzed data from a nation-wide survey of forest advisory committee participants, conducted interviews with sponsoring agencies, and completed two in-depth case studies. We found that sponsors and industry practitioners, like participants, perceived a strong relationship between process and effectiveness. The perspectives of all participants helped us articulate ten key process criteria that they determined as essential for CEG. By including the insights of sponsoring agencies, our study provides both on-the-ground and management interpretations of process and outcomes as well as a nuanced approach to understanding the relationship between the two. However, we conclude that systematic evaluation approaches involving outcome-based criteria are still necessary and would provide a clear step towards encouraging accountability in CEG decision-making, both for sponsors and members.

Robust microorganisms for biofuel and chemical production from municipal solid waste.

BACKGROUND: Worldwide 3.4 billion tonnes of municipal solid waste (MSW) will be produced annually by 2050, however, current approaches to MSW management predominantly involve unsustainable practices like landfilling and incineration. The organic fraction of MSW (OMSW) typically comprises ~ 50% lignocellulose-rich material but is underexplored as a biomanufacturing feedstock due to its highly inconsistent and heterogeneous composition. This study sought to overcome the limitations associated with studying MSW-derived feedstocks by using OMSW produced from a realistic and reproducible MSW mixture on a commercial autoclave system. The resulting OMSW fibre was enzymatically hydrolysed and used to screen diverse microorganisms of biotechnological interest to identify robust species capable of fermenting this complex feedstock. RESULTS: The autoclave pre-treated OMSW fibre contained a polysaccharide fraction comprising 38% cellulose and 4% hemicellulose. Enzymatic hydrolysate of OMSW fibre was high in D-glucose (5.5% w/v) and D-xylose (1.8%w/v) but deficient in nitrogen and phosphate. Although relatively low levels of levulinic acid (30 mM) and vanillin (2 mM) were detected and furfural and 5-hydroxymethylfurfural were absent, the hydrolysate contained an abundance of potentially toxic metals (0.6% w/v). Hydrolysate supplemented with 1% yeast extract to alleviate nutrient limitation was used in a substrate-oriented shake-flask screen with eight biotechnologically useful microorganisms (Clostridium saccharoperbutylacetonicum, Escherichia coli, Geobacillus thermoglucosidasius, Pseudomonas putida, Rhodococcus opacus, Saccharomyces cerevisiae, Schizosaccharomyces pombe and Zymomonas mobilis). Each species' growth and productivity were characterised and three species were identified that robustly and efficiently fermented OMSW fibre hydrolysate without significant substrate inhibition: Z. mobilis, S. cerevisiae and R. opacus, respectively produced product to 69%, 70% and 72% of the maximum theoretical fermentation yield and could theoretically produce 136 kg and 139 kg of ethanol and 91 kg of triacylglycerol (TAG) per tonne of OMSW. CONCLUSIONS: Developing an integrated biorefinery around MSW has the potential to significantly alleviate the environmental burden of current waste management practices. Substrate-oriented screening of a representative and reproducible OMSW-derived fibre identified microorganisms intrinsically suited to growth on OMSW hydrolysates. These species are promising candidates for developing an MSW biorefining platform and provide a foundation for future studies aiming to valorise this underexplored feedstock.

Direct thermal desorption gas chromatographic determination of toxicologically relevant concentrations of ethylene glycol in whole blood.

A simple and rapid method involving thermal desorption gas chromatography (TD-GC) with flame ionisation detection has been successfully developed for the determination of ethylene glycol in whole blood. No sample extraction or derivatization steps were required. The conditions required for the direct determination of ethylene glycol in whole blood were optimised and require only the addition of the internal standard, 1,2-butanediol, to the sample. A 1 µL aliquot of the sample was then introduced to the thermal desorption unit, dried, and thermally desorbed directly to the gas chromatograph. A calibration curve was constructed over the concentration range of 1.0 to 200 mM and was found to be linear over the range investigated with an R2 value of 0.9997. The theoretical limit of detection based on 3σ was calculated to be 50.2 µM (3.11 mg L-1). No issues with carryover were recorded. No interferences were recorded from endogenous blood components or a number of commonly occurring alcohols. The proposed method was evaluated by carrying out replicate ethylene glycol determinations on fortified whole blood samples at the levels of 12.5 mM, 20.0 mM, 31.2 mM, 100 mM and 200 mM comparable to commonly reported blood levels in intoxications. Mean recoveries of between 84.8% and 107% were obtained with coefficients of variation of between 1.7% and 5.8%. These data suggest that the method holds promise for applications in toxicology, where a rapid, reliable method to confirm ethylene glycol poisoning is required.

A problem of social fit? Assessing the role of bridging organizations in the recoupling of socio-ecological systems.

The decoupling of human-ecosystem relationships in underutilized forested or agricultural regions poses a threat to cultural and biological diversities. Some scholars have proposed transformative strategies involving local-led efforts to reconnect social and ecological systems with the support of bridging organizations (BOs). However, empirically-based understandings about how and under what conditions BOs can address context-specific social conditions to enable transformation work remain limited. Using the concept of social fit - how institutional arrangements address contextual social conditions to enhance governance effectiveness - this study examines the work of the Kyoto Model Forest Association (KMFA), a BO, in improving the relationship between forests and people in Kyoto, Japan. We employed a mixed method approach involving a questionnaire survey, document review, semi-structured interviews, and direct observations. Our findings showed that to improve human-ecosystem interdependence, the KMFA prioritized the provision of public education; invested in places and systems to reduce participation costs; built trust and reduced value mismatches; provided incentives and built management capacity; provided leadership to diverse local forestry groups; facilitated institutional integration of forest and non-forest organizations; and drew resources from diverse organizations. These roles broadened the participation of different actors with novel connections to local ecosystems, enhanced self-organizing capacities, and streamlined the roles of forest management institutions. To sustain these efforts, the KMFA needs to continuously adapt to meet the needs and perceptions of diverse and dynamic actors and to broaden participation. Our analysis provides evidence of the efficacy of BOs to recouple human-ecosystem relationships and improve governance outcomes in underutilized social-ecological systems.

Quantitative Detection of Biological Nanovesicles in Drops of Saliva Using Microcantilevers.

Extracellular nanovesicles (EVs) are lipid-based vesicles secreted by cells and are present in all bodily fluids. They play a central role in communication between distant cells and have been proposed as potential indicators for the early detection of a wide range of diseases, including different types of cancer. However, reliable quantification of a specific subpopulation of EVs remains challenging. The process is typically lengthy and costly and requires purification of relatively large quantities of biopsy samples. Here, we show that microcantilevers operated with sufficiently small vibration amplitudes can successfully quantify a specific subpopulation of EVs directly from a drop (0.1 mL) of unprocessed saliva in less than 20 min. Being a complex fluid, saliva is highly non-Newtonian, normally precluding mechanical sensing. With a combination of standard rheology and microrheology, we demonstrate that the non-Newtonian properties are scale-dependent, enabling microcantilever measurements with a sensitivity identical to that in pure water when operating at the nanoscale. We also address the problem of unwanted sensor biofouling by using a zwitterionic coating, allowing efficient quantification of EVs at concentrations down to 0.1 µg/mL, based on immunorecognition of the EVs' surface proteins. We benchmark the technique on model EVs and illustrate its potential by quantifying populations of natural EVs commonly present in human saliva. The method effectively bypasses the difficulty of targeted detection in non-Newtonian fluids and could be used for various applications, from the detection of EVs and viruses in bodily fluids to the detection of molecular clusters or nanoparticles in other complex fluids.

We are better together: nurses' ability to affect change.

The Institute of Medicine has challenged nurses in recent years to practice to the fullest extent of their training and education. This article demonstrates application of this concept by use of example. It describes the processes that a group of nephrology nurses without graduate education who work in direct patient care followed to decrease the rate of transfusion reactions in clients undergoing apheresis receiving fresh frozen plasma fluid replacement.

Generative and predictive neural networks for the design of functional RNA molecules.

RNA is a remarkably versatile molecule that has been engineered for applications in therapeutics, diagnostics, and in vivo information-processing systems. However, the complex relationship between the sequence and structural properties of an RNA molecule and its ability to perform specific functions often necessitates extensive experimental screening of candidate sequences. Here we present a generalized neural network architecture that utilizes the sequence and structure of RNA molecules (SANDSTORM) to inform functional predictions. We demonstrate that this approach achieves state-of-the-art performance across several distinct RNA prediction tasks, while learning interpretable abstractions of RNA secondary structure. We paired these predictive models with generative adversarial RNA design networks (GARDN), allowing the generative modelling of novel mRNA 5' untranslated regions and toehold switch riboregulators exhibiting a predetermined fitness. This approach enabled the design of novel toehold switches with a 43-fold increase in experimentally characterized dynamic range compared to those designed using classic thermodynamic algorithms. SANDSTORM and GARDN thus represent powerful new predictive and generative tools for the development of diagnostic and therapeutic RNA molecules with improved function.

Buildout and integration of an automated high-throughput CLIA laboratory for SARS-CoV-2 testing on a large urban campus.

In 2019, the first cases of SARS-CoV-2 were detected in Wuhan, China, and by early 2020 the first cases were identified in the United States. SARS-CoV-2 infections increased in the US causing many states to implement stay-at-home orders and additional safety precautions to mitigate potential outbreaks. As policies changed throughout the pandemic and restrictions lifted, there was an increase in demand for COVID-19 testing which was costly, difficult to obtain, or had long turn-around times. Some academic institutions, including Boston University (BU), created an on-campus COVID-19 screening protocol as part of a plan for the safe return of students, faculty, and staff to campus with the option for in-person classes. At BU, we put together an automated high-throughput clinical testing laboratory with the capacity to run 45,000 individual tests weekly by Fall of 2020, with a purpose-built clinical testing laboratory, a multiplexed reverse transcription PCR (RT-qPCR) test, robotic instrumentation, and trained staff. There were many challenges including supply chain issues for personal protective equipment and testing materials in addition to equipment that were in high demand. The BU Clinical Testing Laboratory (CTL) was operational at the start of Fall 2020 and performed over 1 million SARS-CoV-2 PCR tests during the 2020-2021 academic year.

Rugby union injuries in Scottish schools.

BACKGROUND: Rugby union is the most popular worldwide collision sport, yet concerns have been raised regarding the safety of the sport due to the physical, high impact nature and an increasing number of injuries. METHODS: A prospective, cohort study of the incidence, pattern and severity of injuries in rugby players in six Scottish schools during the second half of the 2008-09 season. Definition of injury and severity of injury were taken from International Rugby Board (IRB) consensus guidelines. Injury report forms and exposure data for match play were completed by a nominated staff member. RESULTS: Four hundred and seventy consent forms with survey information were returned. Of 37 rugby injuries in the study, 11 occurred during training. Head and face were the most injured body part and sprain/ligament injury the most common injury. Twenty injuries required attendance at Accident & Emergency with one admission. The tackle was the commonest phase of play causing injury. In the 193 matches played, the injury incidence during the match play was 10.8 injuries per 1000 player hours. CONCLUSIONS: This study confirms the feasibility of collecting relevant injury data in schools rugby in Scotland. The findings are consistent with other studies with respect to incidence and profile of injuries sustained.

Electrochemical Strategy for Low-Cost Viral Detection.

Sexually transmitted infections, including the human immunodeficiency virus (HIV) and the human papillomavirus (HPV), disproportionally impact those in low-resource settings. Early diagnosis is essential for managing HIV. Similarly, HPV causes nearly all cases of cervical cancer, the majority (90%) of which occur in low-resource settings. Importantly, infection with HPV is six times more likely to progress to cervical cancer in women who are HIV-positive. An inexpensive, adaptable point-of-care test for viral infections would make screening for these viruses more accessible to a broader set of the population. Here, we report a novel, cost-effective electrochemical platform using gold leaf electrodes to detect clinically relevant viral loads. We have combined this platform with loop-mediated isothermal amplification and a CRISPR-based recognition assay to detect HPV. Lower limits of detection were demonstrated down to 104 total copies of input nucleic acids, which is a clinically relevant viral load for HPV DNA. Further, proof-of-concept experiments with cervical swab samples, extracted using standard extraction protocols, demonstrated that the strategy is extendable to complex human samples. This adaptable technology could be applied to detect any viral infection rapidly and cost-effectively.

Incidence of SARS-CoV-2 infection according to baseline antibody status in staff and residents of 100 long-term care facilities (VIVALDI): a prospective cohort study.

BACKGROUND: SARS-CoV-2 infection represents a major challenge for long-term care facilities (LTCFs) and many residents and staff are seropositive following persistent outbreaks. We aimed to investigate the association between the SARS-CoV-2 antibody status at baseline and subsequent infection in this population. METHODS: We did a prospective cohort study of SARS-CoV-2 infection in staff (aged <65 years) and residents (aged >65 years) at 100 LTCFs in England between Oct 1, 2020, and Feb 1, 2021. Blood samples were collected between June and November, 2020, at baseline, and 2 and 4 months thereafter and tested for IgG antibodies to SARS-CoV-2 nucleocapsid and spike proteins. PCR testing for SARS-CoV-2 was done weekly in staff and monthly in residents. Cox regression was used to estimate hazard ratios (HRs) of a PCR-positive test by baseline antibody status, adjusted for age and sex, and stratified by LTCF. FINDINGS: 682 residents from 86 LCTFs and 1429 staff members from 97 LTCFs met study inclusion criteria. At baseline, IgG antibodies to nucleocapsid were detected in 226 (33%) of 682 residents and 408 (29%) of 1429 staff members. 93 (20%) of 456 residents who were antibody-negative at baseline had a PCR-positive test (infection rate 0·054 per month at risk) compared with four (2%) of 226 residents who were antibody-positive at baseline (0·007 per month at risk). 111 (11%) of 1021 staff members who were antibody-negative at baseline had PCR-positive tests (0·042 per month at risk) compared with ten (2%) of 408 staff members who were antibody-positive staff at baseline (0·009 per month at risk). The risk of PCR-positive infection was higher for residents who were antibody-negative at baseline than residents who were antibody-positive at baseline (adjusted HR [aHR] 0·15, 95% CI 0·05-0·44, p=0·0006), and the risk of a PCR-positive infection was also higher for staff who were antibody-negative at baseline compared with staff who were antibody-positive at baseline (aHR 0·39, 0·19-0·82; p=0·012). 12 of 14 reinfected participants had available data on symptoms, and 11 of these participants were symptomatic. Antibody titres to spike and nucleocapsid proteins were comparable in PCR-positive and PCR-negative cases. INTERPRETATION: The presence of IgG antibodies to nucleocapsid protein was associated with substantially reduced risk of reinfection in staff and residents for up to 10 months after primary infection. FUNDING: UK Government Department of Health and Social Care.

Rapid electrostatic DNA enrichment for sensitive detection of Trichomonas vaginalis in clinical urinary samples.

Estimated to be the most common non-viral sexually transmitted infection globally, Trichomonas vaginalis (TV) can lead to pelvic inflammatory disease, pregnancy complications, and increased risk of acquiring and transmitting HIV. Once diagnosed, TV infection can be treated with oral antibiotics; however, infected individuals are often asymptomatic and do not seek treatment. The WHO and others have identified a need for point-of-care tests to expand access to TV testing and screening; ideal test characteristics include high sensitivity and specificity and the ability to use urine as a sample type, rather than invasively collected swab samples. Here, we report on a proof-of-concept prototype for rapid, electrostatic enrichment of DNA from urine samples and demonstrate the use of large volumes of urine to increase sensitivity of downstream nucleic acid amplification testing. We developed an internally controlled thermophilic helicase-dependent amplification (tHDA) assay with lateral flow immunoassay readout and demonstrate that this tHDA assay can be performed directly on our DNA capture filter. We validated our method using clinical urine samples with qPCR-quantified TV loads. Using 62 clinical urine samples and a simple sample processing device, our tHDA assay displayed 96.6% sensitivity and 100% specificity. Our analytical limit of detection was found to be approximately 7 genomic equivalents of TV DNA per mL of sample when 1 mL of sample was tested, comparable to existing isothermal tests for TV. Using large-volume simulated samples (40 mL of buffered urine with spiked-in TV DNA), we also demonstrated that sensitivity could be improved 28-fold to 0.25 genomic equivalents of TV DNA per mL, with a sample processing time of only 2 minutes.

Recovery from recurrent depression with mindfulness-based cognitive therapy and antidepressants: a qualitative study with illustrative case studies.

OBJECTIVES: This study aimed to describe the recovery journeys of people with a history of recurrent depression who took part in a psychosocial programme designed to teach skills to prevent depressive relapse (mindfulness-based cognitive therapy (MBCT)), alongside maintenance antidepressant medication (ADM). DESIGN: A qualitative study embedded within a multicentre, single blind, randomised controlled trial (the PREVENT trial). SETTING: Primary care urban and rural settings in the UK. PARTICIPANTS: 42 people who participated in the MBCT arm of the parent trial were purposively sampled to represent a range of recovery journeys. INTERVENTIONS: MBCT involves eight weekly group sessions, with four refresher sessions offered in the year following the end of the programme. It was adapted to offer bespoke support around ADM tapering and discontinuation. METHODS: Written feedback and structured in-depth interviews were collected in the 2 years after participants undertook MBCT. Data were analysed using thematic analysis and case studies constructed to illustrate the findings. RESULTS: People with recurrent depression have unique recovery journeys that shape and are shaped by their pharmacological and psychological treatment choices. Their journeys typically include several over-arching themes: (1) beliefs about the causes of depression, both biological and psychosocial; (2) personal agency, including expectations about their role in recovery and treatment; (3) acceptance, both of depression itself and the recovery journey; (4) quality of life; (5) experiences and perspectives on ADM and ADM tapering-discontinuation; and (6) the role of general practitioners, both positive and negative. CONCLUSIONS: People with recurrent depression describe unique, complex recovery journeys shaped by their experiences of depression, treatment and interactions with health professionals. Understanding how several themes coalesce for each individual can both support their recovery and treatment choices as well as health professionals in providing more accessible, collaborative, individualised and empowering care. TRIAL REGISTRATION NUMBER: Clinical trial number ISRCTN26666654; post results.