SMART Family and Friends: Feasibility and outcomes of a video-conference delivered intervention for families impacted by another's methamphetamine use.

INTRODUCTION: Families affected by another's substance use, including methamphetamine, experience harms to their mental and physical health. Yet, research has paid little attention to support and service needs of this population. This pilot study examines the feasibility and outcomes of SMART Family and Friends, a video-conference-delivered mutual-support group targeting families affected by another's methamphetamine use. METHODS: Recruitment for this study occurred between March-October 2021 via the SMART Recovery Australia website. Participants were English-speaking Australian residents, ≥18 years, affected by another's methamphetamine use, interested in participating in a manualised eight-module group delivered via video-conferencing. Feasibility was evaluated by attendance rates, participant satisfaction, fidelity ratings, and semi-structured interviews. Measures of distress, quality of life, and family functioning assessed outcomes at baseline and one-month post-treatment conclusion. RESULTS: Forty-three participants commenced SMART Family and Friends groups. 84 % (n = 36) completed ≥4 modules, 67 % (n = 29) completed ≥6, and 42 % (n = 18) completed all 8 modules. Participant satisfaction (M = 4.32, SD = 0.66, out of 5) and facilitator fidelity (>94 % for all modules) were high. A within-group analysis, without comparison condition demonstrated significant improvements in psychological distress (d = 0.38), family impact (d = 0.64), family strain symptoms (d = 0.48), and total family burden (d = 0.69) post-treatment. Qualitative findings illustrated the benefits and challenges of the video-conference-delivered group, as well as recommendations for improvement. CONCLUSIONS: Results provide initial support for the feasibility and positive outcomes of the SMART Family and Friends program. These findings demonstrate the successful provision of a mutual-support group for affected families delivered via video-conferencing, and merit further sufficiently powered randomised-control-trials to evaluate efficacy.

Five-Year Mortality Outcomes for Eating As Treatment (EAT), a Health Behavior Change Intervention to Improve Nutrition in Patients With Head and Neck Cancer: A Stepped-Wedge, Randomized Controlled Trial.

PURPOSE: Malnutrition affects up to 80% of patients with head and neck cancer (HNC) and is associated with higher burden of disease, poorer treatment outcomes, and greater mortality. The Eating As Treatment (EAT) intervention is a behavioral intervention previously demonstrated to be effective in improving nutritional status, depression, and quality of life in patients with HNC. This article examines the effects of the EAT intervention on 5-year mortality among participants. METHODS AND MATERIALS: A multicenter, stepped-wedge, randomized controlled trial was conducted in 5 Australian hospitals. Dietitians were trained to deliver EAT, a combination of motivational interviewing and cognitive behavior therapy strategies, to patients with HNC receiving radiation therapy. Secondary analyses of survival benefit on an intention-to-treat basis were performed. Differences in proportions of 5-year all-cause mortality between the control and EAT intervention arms were analyzed using multivariable logistic regression, and 5-year survival rates were analyzed using Cox proportional hazards regression. Analyses controlled for temporal effects (study duration), hospital site (clustering), and baseline nutritional status differences. RESULTS: Overall, there were 64 deaths in the 5 years after enrollment, 36 (24%) among those assigned to the control condition and 28 (18%) among those assigned to EAT. Logistic regression showed statistically significant reduced odds in favor of EAT (odds ratio, 0.33; 95% CI, 0.11-0.96), with an absolute risk reduction of 17% (95% CI, 0.01-0.33) and a relative risk reduction of 55% (95% CI, 0.22-0.92), resulting in a number needed to treat of 6 (95% CI, 4-13). Survival analysis revealed that risk of death was significantly reduced by the EAT intervention (hazard ratio, 0.39; 0.16-0.96). CONCLUSIONS: Participation in EAT provided a statistically and clinically meaningful survival benefit, likely via improved nutrition during radiation therapy. This survival benefit strengthens the finding of the main trial, showing that a behavioral intervention focused on nutrition could improve HNC outcomes. Replication studies using stepped-wedge designs for implementation into clinical practice may be warranted.

The benefits and challenges of virtual SMART recovery mutual-help groups: Participant and facilitator perspectives.

BACKGROUND: COVID-19 prompted widespread transition of face-to-face mutual-help groups to virtual delivery. Current understanding of the experience of virtual mutual-help groups is limited to 12-step approaches or asynchronous groups (e.g., forums). This paper explores participant and facilitator perspectives regarding the benefits and challenges of accessing SMART Recovery mutual-help groups virtually via videoconference. METHODS: A self-selected convenience sample of participants (n = 29) and facilitators (n = 15) from SMART Recovery mutual-help groups in Australia were enrolled. Participants and facilitators were sampled to reflect experience of virtual groups delivered via videoconference ('online'), face-to-face groups ('face-to-face') or both types of groups ('both'). Telephone qualitative interviews were conducted using a semi-structured interview guide. Interviews were audio-recorded, transcribed, and analysed using iterative categorisation. RESULTS: Participant and facilitators discussed their experience across eight interconnected themes benefits were typically discussed with regard to the (1) availability, (2) ease of access and (3) value add of the chat feature in online groups. Challenges largely pertained to (1) in-group engagement, (2) group size, (3) non-verbal cues, (4) social interaction and (5) technology problems. The impact of these challenges on participant and facilitator experience varied, and neither modality was consistently identified as superior. CONCLUSIONS: SMART Recovery mutual-help groups provided participants with another option for accessing mutual-help and appealed to different people under different circumstances. Depending on the needs and preferences of the individual, online SMART Recovery mutual-help groups may help to mitigate a range of barriers to help seeking and may also engage people otherwise unable or reluctant to engage in treatment. To inform training, practice and policy, improved understanding of the individual and contextual factors that enhance participant engagement, experience and outcomes is needed.

SMART recovery for youth: a small, exploratory qualitative study examining the potential of a mutual-aid, peer support addictive behaviour change program for young people.

BACKGROUND: SMART (Self-Management and Recovery Training) Recovery is a mutual-aid program informed by cognitive behaviour therapy and motivational interviewing that provides support for a range of addictive behaviours. SMART Recovery has not been adapted to target young people with addictive behaviours despite the potential to overcome important barriers affecting youth engagement in other addiction programs. This study aimed to engage young people and SMART Recovery facilitators in qualitative interviews and focus groups to explore the potential of such a program and gain specific insights for its development. METHODS: We conducted qualitative interviews and a focus group with five young people (aged between 14 and 24 years) and eight key stakeholders (including seven SMART Recovery facilitators) to obtain recommendations on how best to reach, engage, and support young people with addictive behaviours in a tailored SMART Recovery program. Qualitative data was transcribed and analysed using iterative categorization. RESULTS: Five key themes were identified when developing and delivering youth-targeted SMART Recovery. [1] 'Discussing personal experiences to promote a shared identity' refers to the benefits of creating a forum where personal stories are used to connect with others and validate one's experiences. [2] 'Flexible and patient approach' emphasises a preference for facilitators to take a more gentle, less direct approach that allows for discussion beyond addictive behaviours. [3] 'Balancing information and skills with the space for discussion' acknowledges that youth want to connect in a variety of ways, beyond discussion of addictive behaviours, and that they wish to lead skill sharing and development. [4] 'Conveying a community for youth through language' highlighted the need to focus on connecting youth and to avoid the use of generic language to engage young people. [5] 'Group logistics and competing demands' refers to the logistical considerations of implementing a group program for youth that takes into account their competing demands and group accessibility. CONCLUSION: The findings point to considerations for developing youth specific mutual-aid groups, in particular a youth-targeted SMART Recovery program, such as by ensuring the conversation is youth-led and with an informal and flexible approach to guide group discussion.

Adapted motivational interviewing for brief healthcare consultations: A systematic review and meta-analysis of treatment fidelity in real-world evaluations of behaviour change counselling.

BACKGROUND: Behaviour change counselling (BCC) is an adaptation of motivational interviewing (MI) designed to maximize the effectiveness of time-limited health behaviour change consultations. To improve intervention quality and understanding of treatment effects, it is recommended that evaluations of health behaviour change interventions incorporate existing fidelity frameworks (e.g. The National Institutes of Health [NIH] Behaviour Change Consortium) and ensure that treatment fidelity is assessed and reported. PURPOSE: This systematic review was designed to examine (a) adherence to NIH fidelity recommendations, (b) provider fidelity to BCC and (c) impact of these variables on the real-world effectiveness of BCC for adult health behaviours and outcomes. METHODS AND RESULTS: Searches of 10 electronic databases yielded 110 eligible publications describing 58 unique studies examining BCC delivered within real-world healthcare settings by existing providers. Mean study adherence to NIH fidelity recommendations was 63.31% (Range 26.83%-96.23%). Pooled effect size (Hedges g) for short-term and long-term outcomes was .19 (95% CI [.11, .27]) and .09 (95% CI [.04, .13]), respectively. In separate, random-effects meta-regressions, neither short-term nor long-term effect sizes were significantly modified by adherence to NIH fidelity recommendations. For the subgroup of short-term alcohol studies (n = 10), a significant inverse relationship was detected (Coefficient = -.0114, 95% CI [-.0187, -.0041], p = .0021). Inadequate and inconsistent reporting within the included studies precluded planned meta-regression between provider fidelity and BCC effect size. CONCLUSIONS: Further evidence is needed to clarify whether adherence to fidelity recommendations modifies intervention effects. Efforts to promote transparent consideration, evaluation and reporting of fidelity are urgently needed. Research and clinical implications are discussed.

Consistency of Violence: Implications for Effective Inpatient Psychiatric Care.

Instances of violence and aggression in acute psychiatric settings are common and highly distressing for service users and staff. They also incur financial costs. This study aimed to identify the proportion of service users at risk of consistent violence/aggression enactment. It also aimed to analyse associated service use to explore the potential need for specialised, targeted approaches. Five years' worth of data were extracted from 2016 to 2020 on inpatient stays across South London and Maudsley NHS Foundation Trust (SLaM) acute adult wards and Psychiatric Intensive Care Units (PICUs). Service users were divided into cohorts based on relative number of violent/agressive incidents enacted. Differences in frequency of acute service use during the period 1st January-31st December 2020 were analysed. In total, 2524 service users had at least one inpatient stay during 2020. 679 were recorded as having enacted at least one incident of violence or aggression. Just 4% of all service users accounted for 50% of all violence/aggression enactment. Results further showed strong evidence of group differences between violence cohorts in the following domains: internal transfers, occupied bed days, admissions and Place of Safety (PoS) referrals. There was weaker evidence for group differences in referrals to Home Treatment teams (HTTs) and Psychiatric Liaison Teams. A small proportion of service users disproportionately account for the majority of violent and aggressive incidents and higher levels of violence and aggression are associated with more acute service use. The provision of targeted, personalised interventions for this cohort may reduce the enactment of violence and aggression, leading to improved quality life and a reduction in financial expenditure.

The effectiveness of psychosocial interventions for family members impacted by another's substance use: A systematic review and meta-analysis.

INTRODUCTION: Family members affected by another's substance use disorder experience physical health problems, breakdowns in relationships and reduced psychological wellbeing. This review examines the effectiveness of psychosocial interventions for improving the wellbeing of family members. METHODS: A systematic review of randomised-controlled trials (RCT), non-RCTs and pre-post studies examining group or individual interventions for affected families. Five databases were searched (PubMed, PsycINFO, Medline, Web of Science, Cochrane Library). Outcomes included psychological functioning, quality of life, physical health and substance use, family functioning and coping. Outcomes were analysed by study design and mode of delivery (individual or group). Risk of bias was assessed using the Cochrane tools (RoB2, ROBINS-I). The review followed PRISMA reporting guidelines and was prospectively registered with the PROSPERO database (CRD42020200260). RESULTS: Nineteen studies were included (k = 10 included in meta-analyses). In k = 3 RCTs, individually administered interventions significantly reduced depression (standardised mean difference [SMD] 0.50, 95% confidence interval [CI] 0.21, 0.79) and distress (SMD 0.28, 95% CI 0.03, 0.54). In k = 2 pre-post studies, individual interventions improved family functioning (d = 0.51, 95% CI 0.28, 0.73) and coping (d = 0.43, 95% CI 0.24, 0.61). In k = 3 non-RCTs and k = 2 pre-post designs group interventions significantly reduced depression (d = 0.50, 95% CI 0.17, 0.82) and distress (d = 0.44, 95% CI 0.13, 0.75), and improved coping (d = 0.81, 95% CI 0.29, 1.33). DISCUSSION AND CONCLUSIONS: This review summarises the contemporary literature evaluating interventions for affected families, with both individual and group interventions demonstrating favourable outcomes. However, small sample sizes and methodologically weak-quality studies limit conclusions.

Supporting people affected by problematic alcohol, substance use and other behaviours under pandemic conditions: A pragmatic evaluation of how SMART recovery Australia responded to COVID-19.

BACKGROUND: The COVID-19 pandemic prompted rapid, reflexive transition from face-to-face to online healthcare. For group-based addiction services, evidence for the impact on service delivery and participant experience is limited. METHODS: A 12-month (plus 2-month follow-up) pragmatic evaluation of the upscaling of online mutual-help groups by SMART Recovery Australia (SRAU) was conducted using The Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework. Data captured by SRAU between 1st July 2020 and 31st August 2021 included participant questionnaires, Zoom Data Analytics and administrative logs. RESULTS: Reach: The number of online groups increased from just 6 pre-COVID-19 to 132. These groups were delivered on 2786 (M = 232.16, SD = 42.34 per month) occasions, to 41,752 (M = 3479.33, SD = 576.34) attendees. EFFECTIVENESS: Participants (n = 1052) reported finding the online group meetings highly engaging and a positive, recovery supportive experience. 91 % of people with experience of face-to-face group meetings rated their online experience as equivalent or better. Adoption: Eleven services (including SRAU) and five volunteers delivered group meetings for the entire 12-months. IMPLEMENTATION: SRAU surpassed their goal of establishing 100 groups. Maintenance: The average number of meetings delivered [t(11.14) = -1.45, p = 0.1737] and attendees [t(1.95) = -3.28, p = 0.1880] per month were maintained across a two-month follow-up period. CONCLUSIONS: SRAU scaled-up the delivery of online mutual-help groups in response to the COVID-19 pandemic. Findings support the accessibility, acceptability and sustainability of delivering SMART Recovery mutual-help groups online. Not only are these findings important in light of the global pandemic and public safety, but they demonstrate the potential for reaching and supporting difficult and under-served populations.

Online SMART Recovery mutual support groups: Characteristics and experience of adults seeking treatment for methamphetamine compared to those seeking treatment for other addictive behaviours.

INTRODUCTION: The COVID-19 pandemic prompted the transition of Australian Self-Management and Recovery Training (SMART) Recovery mutual support groups to virtual delivery. This study examined the self-reported experience of online SMART Recovery groups for people seeking support for methamphetamine use (alone or in combination with other behaviours) compared to those who did not endorse methamphetamine use as a reason for seeking support. METHODS: An online survey invitation was embedded in the post-group exit page. Items assessed participant demographic characteristics, experience, engagement and perceived contribution of the online group to recovery. Unique responses (n = 1414) were analysed using chi-square. RESULTS: After alcohol, methamphetamine use was the second most common behaviour to prompt online SMART Recovery group attendance (n = 205, 14.5%). People attending for methamphetamine use were more likely to endorse multiple addictive behaviours (n = 137, 66.8% vs. n = 371, 30.7%, p < 0.001). Irrespective of whether people attended for methamphetamine use or not, participant ratings of experience, engagement and perceived contribution to recovery were positive and largely comparable. People attending for methamphetamine use were significantly less likely to set a 7-day plan (72.7% vs. 81.9%; χ2  = 9.47, p = 0.002). DISCUSSION AND CONCLUSIONS: Findings support the acceptability of online SMART Recovery groups for people experiencing addictive behaviours, including methamphetamine use. To maximise the benefits of these groups, further evidence on how best to support people to develop a change plan within a time-limited, online group setting is needed. Online mutual support groups may help to reach and support people who might not otherwise engage in treatment and support, including people who use methamphetamine.

Associations between violence, self-harm and acute psychiatric service use: Implications for inpatient care.

WHAT IS KNOWN ON THE SUBJECT?: Service users who behave violently may suffer. This is because violence can lead to unnecessary medication, seclusion on the ward and strained relationships with other people. It can also affect a service user's self-esteem and lead to feelings of shame. Service users who behave violently can also make life frightening and unpredictable for members of staff, and other service users on the ward. It is important to gain a sound understanding of violence in order to help reduce it. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Previous research has shown that having a past history of violence, being admitted to PICU and being admitted to hospital under section is associated with violent behaviour on the ward. We identified several new factors associated with violent behaviour, such as engaging in self-harm, being the target of another person's violence and being referred to a Psychiatric Liaison Team. IMPLICATIONS FOR PRACTICE: For some service users, behaving violently may be a response to previous trauma and an expression of distress. It is therefore important that mental health nurses are supported by their employers to work with service users in a trauma-informed manner. Nurses employed across a range of psychiatric settings could benefit from direct interventions such as comprehensive trauma-informed care training and psychological debrief spaces, or systemic interventions to address staff shortages and improve ward conditions. ABSTRACT: INTRODUCTION: Instances of violence in acute psychiatric settings are frequent, can be devastating for service users and staff, and are costly. Such settings would benefit from a greater understanding of violence. AIM: We analysed the association between current and historical variables and rates of inpatient violence. To address gaps in current research, we included instances of self-harm and being the target of violence. We also included seldom used service metrics. METHOD: Data were extracted on admissions to acute adult wards and PICUs 2017-2020 within South London and Maudsley NHS Foundation Trust. A zero-inflated negative binomial regression mixed model was used to analyse the impact of variables on rates of violence. RESULTS: Variables associated with an increased rate of violence were as follows: an increased number of violent incidents in the year before admission, being admitted on MHA section, being admitted to PICU, instances of self-harm, being the target of violence and referral to a Psychiatric Liaison Team. DISCUSSION: The novel associations found between enacting violence, self-harm and being the target of violence indicate trauma-informed care is crucial to reduce violent presentations of distress. IMPLICATIONS FOR PRACTICE: System level interventions are crucial to ensure mental health nurses are supported to provide trauma-informed care.

Smoking and other health factors in patients with head and neck cancer.

BACKGROUND: Information on smoking and other health factors in head and neck cancer (HNC) patients throughout treatment, follow-up and survivorship is limited. This study explores patterns of multiple health factors during radiotherapy (RT) and naturalistic long-term follow-up in a convenience sample of patients with HNC. METHODS: Smoking, alcohol use and depression were measured at baseline, 4 and 12 weeks post RT for a sub-group of 99 patients who participated in a randomised controlled trial and completed long-term follow-up. These factors plus healthy eating, physical activity and fatigue are also reported from the long-term follow-up component. Smoking was measured by self-report and biochemically, whilst all other variables were by self-report. Where variables were assessed at multiple time points logistic mixed effects regression models determined within-person changes over time. RESULTS: There were important discrepancies between self-reported (4-7%) and biochemically verified (13-29%) rates of smoking. Rates of smoking and hazardous alcohol intake were significantly increased at follow-up compared to baseline. Depression rates were observed to be higher at end of RT compared to baseline. At long-term follow-up, fatigue was common and co-occurred with suboptimal healthy eating and hazardous alcohol use. CONCLUSION: Clinically important levels of smoking and alcohol consumption post RT in this sample suggest possible targets for intervention beyond treatment into long-term follow-up of patients.

Staff support in a National Health Service mental health trust in response to the COVID-19 pandemic: qualitative study.

BACKGROUND: The COVID-19 pandemic has highlighted the impact work can have on healthcare workers and the importance of staff support services. Rapid guidance was published to encourage preventive and responsive support for healthcare workers. AIMS: To understand mental healthcare staff's help-seeking behaviours and access to support at work in response to the COVID-19 pandemic, to inform iterative improvements to provision of staff support. METHOD: We conducted a formative appraisal of access to support and support needs of staff in a National Health Service mental health trust. This involved 11 semi-structured individual interviews using a topic guide. Five virtual staff forums were additional sources of data. Reflexive thematic analysis was used to identify key themes. RESULTS: Peer-based, within-team support was highly valued and sought after. However, access to support was negatively affected by work pressures, physical distancing and perceived cultural barriers. CONCLUSIONS: Healthcare organisations need to help colleagues to support each other by facilitating open, diverse workplace cultures and providing easily accessible, safe and reflective spaces. Future research should evaluate support in the evolving work contexts imposed by COVID-19 to inform interventions that account for differences across healthcare workforces.

Early Advanced Therapy for Diabetic Foot Ulcers in High Amputation Risk Veterans: A Cohort Study.

Veterans with diabetic foot ulcers (DFUs) represent the highest percentage of lower extremity amputations (LEAs) within the Veterans Affairs (VA) population. Many veterans have additional risk factors for amputation. Few studies focus on advanced therapies for this population. This study explores the impact of early application of dehydrated human amniotic membrane allograft (DAMA) with comprehensive care on preventing amputation. This prospective, single-center cohort study (ClinicalTrials.gov Identifier NCT02632929) was conducted through Boise VA Medical Center. Patients with DFUs were objectively stratified for LEA risk. Those with moderate to high amputation risk could participate. Participants received comprehensive care and weekly application of DAMA. Primary endpoint was avoidance of major LEA. Secondary endpoint was wound epithelialization. Monitoring continued 4 months. Between July 2015 and March 2017, 20 patients (mean age 67.2 years) with 24 DFU classified as moderate (12 wounds) to high risk (12 wounds) for amputation were enrolled. Wound volumes ranged from 0.072 cm3 to 56.4 cm3. Risk factors included neuropathy (20 patients), osteomyelitis (16 wounds), exposed tendon/ligament/bone (19 wounds), Charcot (5 patients), and peripheral arterial disease (13 wounds). All subjects avoided amputation within the study period, all 24 wounds achieved re-epithelialization within 4 to 33 weeks; mean healing time 13.2 weeks. Cost for the DAMA tissue ranged from $750 to $38 150. Estimated cost for LEA ranges from $30 000 to $50 000. No treatment-related adverse events during the study period were reported. The results suggest that early and frequent application of DAMA with comprehensive care may help prevent amputation. Additional research will help inform third-party payors and clinicians.

Feasibility of a Mobile Health App for Routine Outcome Monitoring and Feedback in SMART Recovery Mutual Support Groups: Stage 1 Mixed Methods Pilot Study.

BACKGROUND: Mutual support groups are an important source of long-term help for people impacted by addictive behaviors. Routine outcome monitoring (ROM) and feedback are yet to be implemented in these settings. SMART Recovery mutual support groups focus on self-empowerment and use evidence-based techniques (eg, motivational and behavioral strategies). Trained facilitators lead all SMART Recovery groups, providing an opportunity to implement ROM. OBJECTIVE: The aim of this stage 1 pilot study is to explore the feasibility, acceptability, and preliminary outcomes of a novel, purpose-built mobile health ROM and feedback app (SMART Track) in mutual support groups coordinated by SMART Recovery Australia (SRAU) over 8 weeks. METHODS: SMART Track was developed during phase 1 of this study using participatory design methods and an iterative development process. During phase 2, 72 SRAU group participants were recruited to a nonrandomized, prospective, single-arm trial of the SMART Track app. Four modes of data collection were used: ROM data directly entered by participants into the app; app data analytics captured by Amplitude Analytics (number of visits, number of unique users, visit duration, time of visit, and user retention); baseline, 2-, and 8-week follow-up assessments conducted through telephone; and qualitative telephone interviews with a convenience sample of study participants (20/72, 28%) and facilitators (n=8). RESULTS: Of the 72 study participants, 68 (94%) created a SMART Track account, 64 (88%) used SMART Track at least once, and 42 (58%) used the app for more than 5 weeks. During week 1, 83% (60/72) of participants entered ROM data for one or more outcomes, decreasing to 31% (22/72) by the end of 8 weeks. The two main screens designed to provide personal feedback data (Urges screen and Overall Progress screen) were the most frequently visited sections of the app. Qualitative feedback from participants and facilitators supported the acceptability of SMART Track and the need for improved integration into the SRAU groups. Participants reported significant reductions between the baseline and 8- week scores on the Severity of Dependence Scale (mean difference 1.93, SD 3.02; 95% CI 1.12-2.73) and the Kessler Psychological Distress Scale-10 (mean difference 3.96, SD 8.31; 95% CI 1.75-6.17), but no change on the Substance Use Recovery Evaluator (mean difference 0.11, SD 7.97; 95% CI -2.02 to 2.24) was reported. CONCLUSIONS: Findings support the feasibility, acceptability, and utility of SMART Track. Given that sustained engagement with mobile health apps is notoriously difficult to achieve, our findings are promising. SMART Track offers a potential solution for ROM and personal feedback, particularly for people with substance use disorders who attend mutual support groups. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12619000686101; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377336. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/15113.

FullFix: a randomised controlled trial of a telephone delivered transdiagnostic intervention for comorbid substance and mental health problems in young people.

INTRODUCTION: Transdiagnostic cognitive-behavioural therapy (CBT) targets common psychological factors that underlie multiple disorders. While transdiagnostic interventions are a promising new approach, limited research has evaluated these treatments within the alcohol and other drug (AOD) sector for young people with comorbid mental health symptoms. This project will examine the feasibility and preliminary efficacy of FullFix-a new risk-targeted transdiagnostic CBT telehealth programme for comorbid AOD and depression/anxiety disorders in young people. Secondary aims are to identify moderators and mediators of treatment outcomes, to determine how and why treatment is effective and who is most likely to benefit. METHODS/DESIGN: Participants will be 130 young people (aged 16-35) accessing AOD services in Queensland, Australia, with comorbid mental health symptoms. They will be randomised to receive either the FullFix intervention plus standard AOD care or standard AOD care alone. Primary outcomes on AOD use and mental health symptoms will be reassessed at 6 weeks, 3 months, 6 months and 12 months, along with secondary outcomes of emotion regulation, social connectedness, perceived self-efficacy, coping skills and quality of life. The trial commenced on October 2018 and expected completion date is September 2021. ETHICS AND DISSEMINATION: Ethical approval for this trial was provided by the University of Queensland (#2018001185). The results of the trial will be disseminated through publication in a peer-reviewed scientific journal, scientific presentations at conferences and distributed via a report and presentations to the partner organisation. TRIAL REGISTRATION NUMBER: ACTRN12618001563257.

SMART Recovery International and COVID-19: Expanding the reach of mutual support through online groups.

BACKGROUND: Mutual support groups play an extremely important role in providing opportunities for people to engage in alcohol and other drug (AOD) treatment and support. SMART Recovery groups employ cognitive, behavioural and motivational principles and strategies to offer support for a range of addictive behaviours. COVID-19 fundamentally changed the way that these groups could be delivered. METHODS: A series of online meetings were conducted by the lead author (PK) and the SMART Recovery International Executive Officer (KM), with representatives from the SMART Recovery National Offices in the Ireland (DO), United States (MR), Australia (RM), and Denmark (BSH, DA), and the United Kingdom (AK). The meetings focused on discussing the impacts of COVID-19 on SMART Recovery in each of the regions. RESULTS: As a result of restrictions to prevent the transmission of COVID-19, the vast majority of SMART Recovery face-to-face meetings were required to cease globally. To ensure people still had access to AOD mutual support, SMART Recovery rapidly scaled up the provision of online groups. This upscaling has increased the number of groups in countries that had previously provided a limited number of online meetings (i.e., United States, England, Australia), and has meant that online groups are available for the first time in Denmark, Ireland, Hong Kong, Spain, Malaysia and Brazil. DISCUSSION: Whilst the urgent and rapid expansion of online groups was required to support people during the pandemic, it has also created an opportunity for the ongoing availability of online mutual support post-pandemic. The challenge for the research community is to critically evaluate the online delivery of mutual support groups, to better understand the mechanisms through which they may work, and to help understand the experience of people accessing the groups.

Developing a mHealth Routine Outcome Monitoring and Feedback App ("SMART Track") to Support Self-Management of Addictive Behaviours.

Background: Routine outcome monitoring (ROM) has been implemented across a range of addiction treatment services, settings and organisations. Mutual support groups are a notable exception. Innovative solutions are needed. SMART Track is a purpose built smartphone app designed to capture ROM data and provide tailored feedback to adults attending Australian SMART Recovery groups for addictive behaviour(s). Objective: Details regarding the formative stage of app development is essential, but often neglected. Improved consideration of the end-user is vital for curtailing app attrition and enhancing engagement. This paper provides a pragmatic example of how principles embedded in published frameworks can be operationalised to address these priorities during the design and development of the SMART Track app. Methods: Three published frameworks for creating digital health technologies ("Person-Based Approach," "BIT" Model and IDEAS framework) were integrated and applied across two stages of research to inform the development, design and content of SMART Track. These frameworks were chosen to ensure that SMART Track was informed by the needs and preferences of the end-user ("Person-Based"); best practise recommendations for mHealth development ("BIT" Model) and a collaborative, iterative development process between the multi-disciplinary research team, app developers and end-users (IDEAS framework). Results: Stage one of the research process generated in-depth knowledge to inform app development, including a comprehensive set of aims (clinical, research/organisation, and usage); clear articulation of the target behaviour (self-monitoring of recovery related behaviours and experiences); relevant theory (self-determination and social control); appropriate behavioural strategies (e.g., behaviour change taxonomy and process motivators) and key factors that may influence engagement (e.g., transparency, relevance and trust). These findings were synthesised into guiding principles that were applied during stage two in an iterative approach to app design, content and development. Conclusions: This paper contributes new knowledge on important person-centred and theoretical considerations that underpin a novel ROM and feedback app for people with addictive behaviour(s). Although person-centred design and best-practise recommendations were employed, further research is needed to determine whether this leads to improved usage outcomes. Clinical Trial Registration: Pilot Trial: http://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377336.

The relationship between ethnic background and the use of restrictive practices to manage incidents of violence or aggression in psychiatric inpatient settings.

Restrictive practices raise considerable concern in mental health inpatient care. Previous studies suggest there are disparities in the use of restrictive practices to manage service users of different ethnic groups. The present study analyses the relationship between ethnicity and the use of restrictive practices to manage incidents of violence or aggression in inpatient settings across an NHS Mental Health Trust. Three years' worth of routinely collected incident data were analysed using multilevel multiple logistic regression to assess the relationship between ethnic group and four types of restrictive practices: physical restraint (without prone), physical restraint (with prone), seclusion, and rapid tranquilization. We controlled for a range of demographic variables and the type and severity of the incident. Adjusted analyses showed that service users with a Black African [Odds Ratio = 1.96, 95% CI: 1.36-2.83, P < 0.001], Black Caribbean [Odds Ratio = 1.76, 95% CI: 1.08-2.85, P = 0.022], Black Other [Odds Ratio = 1.76, 95% CI: 1.27-2.44, P = 0.001], and Mixed [Odds Ratio = 1.88, 95% CI: 1.11-3.18, P = 0.019] ethnic background were more likely to be secluded, and Black Caribbean [Odds Ratio = 1.45, 95% CI: 1.02-2.07, P = 0.040] service users were more likely to be restrained in prone position. We did not detect differences in the use of physical restraints without prone or in the use of rapid tranquilization. Our findings illustrate the need to focus on outcomes for different ethnic groups when implementing restraint reduction programmes.

The use of Australian SMART Recovery groups by people who use methamphetamine: Analysis of routinely-collected nationwide data.

INTRODUCTION: Mutual support groups (e.g. SMART Recovery) are an important source of support for people experiencing addictive behaviours. Little is known about the use of mutual support groups by people who use methamphetamine, or the factors that may influence group cohesion. METHODS: This study uses post-group data reported by SMART Recovery facilitators in Australia between 2018 and 2020. Group cohesion was indexed by facilitator ratings of The Group Entitativity measure (GEM-GP). Participant characteristics (gender, age, new or returning group member, voluntary or mandated attendance) and group location (major city vs. regional/remote vs. online) were used to (a) compare methamphetamine and non-methamphetamine related attendances; and (b) explore relationships to group cohesion within groups where the majority attended for methamphetamine. RESULTS: Methamphetamine use was the second most common reason for attending SMART Recovery groups (n = 4929; 22.2 % service occasions). Methamphetamine-related service occasions were more likely amongst men, people aged <45 years, returning attendees and regional/rural groups (allp < .05). GEM-GP scores were high (signalling strong cohesion), and did not significantly differ according to proportion of participants attending for methamphetamine (F(1,2) = 0.482, p = .618). Group cohesion increased with larger group size, proportion of women and proportion of younger people (F(4, 504) = 11.058, p < .001)). DISCUSSION AND CONCLUSIONS: This study improves current understanding of service utilisation by people who use methamphetamine. SMART Recovery groups offer an avenue for supporting a diverse range of people who use methamphetamine, outside the formal treatment system. This provides an important foundation for improving community support options for people who use methamphetamine.

Is fidelity to a complex behaviour change intervention associated with patient outcomes? Exploring the relationship between dietitian adherence and competence and the nutritional status of intervention patients in a successful stepped-wedge randomised clinical trial of eating as treatment (EAT).

BACKGROUND: Behavioural medicine is characterised by findings for the effectiveness and efficacy of complex behaviour change interventions. Comparatively, scant attention has been paid to key intervention components or mechanisms of action. Evaluating relationships between process variables (fidelity) and intervention effects is central to addressing this imbalance. Accordingly, in the current study, we sought to explore the magnitude and direction of effect between fidelity predictors (dietitian adherence and competence) and intervention effects (patient nutritional status) during the intervention phase of a real-world, stepped-wedge evaluation of 'EAT: Eating As Treatment'. METHODS: The EAT clinical trial was conducted within five major Australian hospitals located in Queensland, Western Australia, Victoria and South Australia between 2013 and 2016. EAT is a dietitian-delivered health behaviour change intervention designed to reduce malnutrition in head and neck cancer (HNC) patients undergoing radiotherapy. Dietitian adherence and competence ratings were derived from a 20% random sample of audio-recorded dietetic consultations (n=194) conducted after dietitians (n=18) were trained in EAT. Sessions were coded by trained, independent, coders using a study checklist, the Behaviour Change Counselling Index (BECCI) and items from the Cognitive Therapy Scale-Revised (CTS-R). Patient nutritional status was measured using the Patient-Generated Subjective Global Assessment (PGSGA). RESULTS: Dietitian adherence to a written nutrition plan (ß=7.62, 95% CI=0.65 to 14.58, p=0.032), dietitian adherence to behaviour change counselling (ß=0.69, 95% CI =0.02 to 1.38, p=0.045) and competence in delivering behaviour change counselling (ß=3.50, 95% CI =0.47 to 6.53, p=0.024) were significant predictors of patient nutritional status. Dietitian adherence and competence ratings were higher during consultations with intervention patients at greater risk of malnutrition. CONCLUSIONS: This study contributes new insights into the relationship between fidelity and treatment outcome by demonstrating that dietitian adherence and competence is greater when working with more challenging patients. This is likely central to the demonstrated success of the EAT intervention in reducing malnutrition and highlights the importance of ensuring that providers are adequately equipped to flexibly integrate intervention elements according to patient need. TRIAL REGISTRATION: This study is a process analysis of a stepped-wedge randomised controlled trial prospectively registered on the Australian New Zealand Clinical Trials Registry ( ACTRN12613000320752 ; Date of registration 21/03/2013).