Beyond theoretical courses - A study of Swedish psychiatric residents' collegial learning through conversations in the workplace.

BACKGROUND: Collegial conversations are important for sustainable learning to last beyond a course. Research on collegial conversations and peer learning in the workplace during psychiatric residency courses remains sparse, however. In this study, the aim was to explore residents' opportunities for collegial conversations during and after national courses in psychiatry. METHODS: Residents in psychiatry completed an online survey including questions on opportunities for collegial conversations in their workplaces. Logistic regression was used for multivariate analysis and thematic content analysis was used for the open-ended answers where a theoretical framework of communities of practice was employed for the interpretation of the findings. RESULTS: The survey was completed by 112 residents out of 725 (15,4%). The participants reported few structured forums for collegial discussion. The results of multivariate analysis suggest that more women than men feel it is advantageous to attend courses with others from the same workplace or from the same group of residents, described here as a team. The analysis of qualitative data identified how opportunities for collegial conversations differ across contexts and the type of values that are attached to team participation in residency courses. CONCLUSIONS: This study highlights the importance of collegial conversations as a way to sustain the learning from residency courses into the workplace. By learning about residents' perceptions of collegial conversations during and after courses, teachers and directors may be more able to support residents' lifelong learning and professional development.

Physical Versus Virtual Reality-Based Calm Rooms for Psychiatric Inpatients: Quasi-Randomized Trial.

BACKGROUND: Interest in sensory rooms or so-called "calm rooms" in psychiatric inpatient care has increased significantly. In a hospital setting, their purpose is to introduce a relaxing environment to increase well-being as well as to decrease anxiety and aggressive behaviors. Calm rooms can also be used as a tool to provide self-help through a convenient environment for the patients and, at the same time, strengthen the therapeutic relationship between the patient and the professional. Recent developments in virtual reality (VR) have made virtual calm rooms possible, but these have not yet been evaluated in psychiatric inpatient care. OBJECTIVE: This study aimed to compare the effects of VR and physical calm rooms on self-reported well-being and physiological markers of arousal. METHODS: The study was conducted in 2 inpatient psychiatric wards specializing in bipolar disorder from March 2019 to February 2021. Patients who were already admitted were asked if they were interested in using a calm room and willing to provide ratings. This study relied on the quasi-randomized allocation of patients to the wards, which either had a physical or VR calm room. Self-assessment scales (Montgomery-Åsberg Depression Rating Scale-Self Assessment [MADRS-S], Beck Anxiety Scale, and Clinical Global Impression) were used to determine the participants' baseline level of depressive and anxiety symptoms before their use of the physical or VR calm room. The study determined the state of well-being measured using an 11-point visual analog scale (VAS) as well as arousal measured by blood pressure (systolic and diastolic) and heart rate before and after the use of the calm rooms. The primary end point was self-reported well-being using the VAS. RESULTS: A total of 60 participants were included-40 used the VR calm room and 20 used the physical calm room. The mean age of participants was 39 years and the majority were women (35/60, 58%). Analysis of VAS measurement showed improved well-being at the group level from before to after the intervention (P<.05), with no statistically significant difference in effects between the 2 different interventions. Effects were not moderated by baseline depression levels (dichotomized as MADRS-S >20 or ≤20) despite an overall difference in reported well-being between subgroups. CONCLUSIONS: Although the power in this study was low, the findings of this first study indicate comparable effects with respect to well-being and arousal of a VR calm room and a physical calm room. This suggests that a VR calm room can be a viable alternative when the use of a physical calm room is not an option for logistic or other reasons. TRIAL REGISTRATION: ClinicalTrials.gov NCT03918954; https://clinicaltrials.gov/ct2/show/NCT03918954.

Air pollution and increased number of psychiatric emergency room visits: A case-crossover study for identifying susceptible groups.

BACKGROUND: Ambient particulate matter is a leading risk factor for disease globally. Particulate matter 10 (PM10) and particulate matter 2.5 (PM2.5) are derived from different sources, including operating motor vehicles as well as from industrial activities. In this study we investigate the association between increased concentrations of PM and total daily visits to the psychiatric emergency unit (PEV). Further, the aim is to identify specific risk groups who are more susceptible to the effects of air pollution exposure by studying sex, age, ongoing psychiatric follow-up and diagnoses of depression/anxiety or substance use. MATERIAL AND METHODS: The sample was comprised of data from 2740 days to 81 548 PEVs at Sahlgrenska University Hospital in Gothenburg and daily mean concentrations of PM10 and PM2.5. A time-stratified case-crossover design was used to analyse associations between air pollution and PEVs. RESULTS: Mean number of daily PEVs were 35 and sex distribution was even. PM exposure was associated with total PEV at lag 0 (the same day), by RR 1.016 (95% confidence interval [CI] 1.004-1.028) and RR 1.020 (95%CI 1.003-1.038) per 10 µg/m3 increase in PM10 and PM2.5, respectively. In females, PEV were increased at lag 0 and lag 1, and in males at lag 1 and lag 2. In the age-stratified analysis, PEVs significantly increased following PM exposure amongst individuals aged 35-65 years by lag 0-2 and in individuals who had contact with outpatient care at lag 0 to lag 1. There were no associations between air pollution and PEVs for any specific diagnostic group evaluated (amongst depression, anxiety and substance use disorder). CONCLUSIONS: The results indicate that acute exposure to PM10 and PM2.5 may trigger acute worsening in mental health in both males and females, especially among 35-65 year old individuals. However, in subgroups of the most common psychiatric diagnoses, we did not observe statistically significant associations with PM exposure.

Prevalence of virtual reality (VR) games found through mental health categories on STEAM: a first look at VR on commercial platforms as tools for therapy.

BACKGROUND: Immersive virtual reality (VR) games are increasingly becoming part of everyday life. Several studies support immersive VR technology as a treatment method for mental health problems. There is however little insight into the prevalence of commercially available VR games for treatment of mental health problems on commercial platforms such as STEAM, and to what extent they can be used as tools for treatment or add-on treatment of mental health problems. OBJECTIVE: The aim of this study was to take a first look at the prevalence and overview of content of commercially available games. The games were found using search words related to psychiatric diagnosis or care. METHODS: We performed a search for keywords related to symptoms, diagnosis, and treatment strategies of mental health problems. The search was performed November 2020 on STEAM. A scheme was created for elimination and inclusion of games, eliminating those games which were irrelevant to mental health or had triggering elements such as violence, excessive movement which could trigger nausea, horror and pornographic imagery. RESULTS: In total, 735 hits were found, 565 unique games. After the games were reviewed for content via trailers, descriptions and screenshots, 32%, i.e. 182 games passed the inclusion criteria. Majority of the games which were excluded were either not connected to mental health, contained violence, adult content or were in other ways irrelevant or inappropriate. CONCLUSIONS: Commercial platforms are only at the beginning of the development towards therapeutic content. Currently the quality and usability for therapeutic use is scarce but holds great potential.

Weighted blanket and sleep medication use among adults with psychiatric diagnosis - a population-based register study.

OBJECTIVE: To measure rate of subscription of common sleep medication and diagnoses of substance use disorder (SUD) before and after receiving a prescribed weighted blanket (WB) among patients with psychiatric diagnoses. MATERIALS AND METHODS: Using register-based data of health-related factors in a Swedish region, a total of 1785 adult individuals with a psychiatric diagnosis, received a WB and resided in the region during the study period were identified. Using each individual as their own control, the rate of one-year prior prescription of WB or diagnosed SUD was compared to rate after a half year wash-out after prescription of WB for a full year. RESULTS: The number of patients without prescription of sleep medication increased by 3.3% (95% confidence interval (95%CI): 0.2-6.4, p=.04). Furthermore, the proportion without a prescription of benzodiazepine receptor agonist/antihistamines sleep medication increased by 5.5% (95%CI: 2.2-8.8, p=.001). Melatonin prescription increased after WB by 3.6% (95%CI: 1.1-6.2, p=.006). Younger age and unipolar-, anxiety-, attention-deficit/hyperactivity-, and post-traumatic stress disorder was associated with decreased use while psychotic-/bipolar- and personality disorder was not associated with a decrease in the use of sleep medication. The number of alcohol SUD diagnoses did not increase while sedative SUD rate increased statistically significantly by 0.7% (odds ratio = 1.63, p=.02). In a multivariate model, only younger age predicted discontinuation of sleep medication while psychotic-/bipolar- and personality disorder had statistically less decrease. CONCLUSION: This observational register study found a statistically significant association between WB use and decreased use of common sleep medication except melatonin that increased slightly.

Sleep deprivation as treatment for depression: Systematic review and meta-analysis.

OBJECTIVE: To systematically review evidence on the efficacy and safety of sleep deprivation (SD) as a treatment option for patients with unipolar or bipolar depression. METHODS: A systematic review according to PRISMA guidelines was conducted. The certainty of evidence was assessed using the GRADE approach. Controlled trials were included in efficacy analysis, case series for evaluating complications and qualitative studies for patients' experiences. RESULTS: Eight controlled studies (368 patients), one qualitative study and seven case series (825 patients) were included. One week after treatment start, SD combined with standard treatment did not reduce depressive symptoms compared with standard treatment (standardized mean difference, SMD = -0.29, [95% confidence interval, CI: -0.84 to 0.25], p = 0.29). When excluding a study in elderly patients in a post hoc analysis, the difference was statistically significant (SMD = -0.54 ([95% CI: -0.86 to -0.22], p < 0.001)) but it diminished two weeks after treatment start. No superiority of SD was found compared with antidepressants, but SD may be superior to exercise in certain settings. It is uncertain whether SD affects quality of sleep, quality of life, everyday functioning or length of stay. Apart from switch to mania (ranging between 2.7% and 10.7%), no other serious complications were reported. CONCLUSION: Sleep deprivation has been studied in a wide range of settings resulting in divergent results for the short-term efficacy on depressive symptoms. Post hoc analyses indicated that there may be a significant but transient effect in certain populations. Further studies should focus on identifying subgroups of responders as well as examining feasibility in routine clinical care.

Problematic Alcohol and Drug Use Is Associated with Low Self-Directedness and Cooperativeness.

BACKGROUND: Personality traits, such as self-directedness (SD) and cooperativeness (CO), may be indicative of problematic alcohol and/or drug use. OBJECTIVES: The aim of this study was to quantify the association of substance use with SD and CO in a large cohort of adolescents. METHOD: A total of 6,917 individuals (58% women) at the age of 18 who had filled in the Alcohol Use Disorder Identification Test (AUDIT) and Drug Use Disorder Identification Test (DUDIT), and the SD and CO scales from the Temperament and Character -Inventory, as part of the Child and Adolescent Twin study in Sweden were included in the analyses. RESULTS: High AUDIT scores (>15) were found in 2.4% of the population and high DUDIT scores (>7) in 1.2% of the population. Total score on the AUDIT was negatively correlated (p < 0.001) with SD (r = -0.18) and CO (r = -0.15), as well as total DUDIT with SD (r = -0.11) and CO (r = -0.08). The risk of high AUDIT (>15) and DUDIT (>7) was highest for those with a low (1 standard deviation below mean) SD score (ORs 4.1 and 4.5, p < 0.001) and a low CO score (ORs 3.5 and 4.5, p < 0.001). However, at 1 standard deviation above mean, no association between alcohol or drug use and SD or CO was seen. Using SD and CO scores to predict AUDIT >15 or DUDIT >7 yielded a sensitivity between 62.4 and 71.3% and a specificity between 64.9 and 70.4%. CONCLUSIONS: Personality traits of low SD and CO are associated with increased alcohol and drug use. These findings support the notion that personality traits can be used to identify individuals at high risk of substance abuse.

The association between daily concentrations of air pollution and visits to a psychiatric emergency unit: a case-crossover study.

BACKGROUND: Air pollution is one of the leading causes of mortality and morbidity worldwide. Experimental studies, and a few epidemiological studies, suggest that air pollution may cause acute exacerbation of psychiatric disorders, and even increase the rate of suicide attempts, but epidemiological studies on air pollution in association with psychiatric disorders are still few. Our aim was to investigate associations between daily fluctuations in air pollution concentrations and the daily number of visits to a psychiatric emergency unit. METHODS: Data from Sahlgrenska University Hospital, Gothenburg, Sweden, on the daily number of visits to the Psychiatric emergency unit were combined with daily data on monitored concentrations of respirable particulate matter(PM10), ozone(O3), nitrogen dioxides(NO2) and temperature between 1st July 2012 and 31st December 2016. We used a case-crossover design to analyze data with conditional Poisson regression models allowing for over-dispersion. We stratified data on season. RESULTS: Visits increased with increasing PM10 levels during the warmer season (April to September) in both single-pollutant and two-pollutant models. For example, an increase of 3.6% (95% Confidence Interval, CI, 0.4-7.0%) was observed with a 10 µg/m3 increase in PM10 adjusted for NO2. In the three-pollutant models (adjusting for NO2 and O3 simultaneously) the increase was 3.3% (95% CI, -0.2-6.9). There were no clear associations between the outcome and NO2, O3, or PM10 during the colder season (October to March). CONCLUSIONS: Ambient air particle concentrations were associated with the number of visits to the Psychiatric emergency unit in the warm season. The results were only borderline statistically significant in the fully adjusted (three-pollutant) models in this small study. The observation could be interpreted as indicative of air pollution as either exacerbating an underlying psychiatric disorder, or increasing mental distress, even in areas with comparatively low levels of air pollution. In combination with the severe impact of psychiatric disorders and mental distress on society and individuals, our results are a strong warrant for future research in this area.

Sternal wound infections following open heart surgery - a review.

Surgical site infections (SSIs) are common complications after open heart surgery. Fortunately, most are superficial and respond to minor wound debridement and antibiotics. However, 1-3% of patients develop deep sternal wound infections that can be fatal. Late infections with sternocutaneous fistulas, are encountered less often, but represent a complex surgical problem. This evidence-based review covers etiology, risk factors, prevention and treatment of sternal SSIs following open heart surgery with special focus on advances in treatment, especially negative-pressure wound therapy.

Intravenous Use of Prescription Psychostimulants; A Comparison of the Pattern and Subjective Experience between Different Methylphenidate Preparations, Amphetamine and Cocaine.

BACKGROUND/AIMS: Methylphenidate (MPH) has been the most commonly used intravenous (i.v.) substance in Iceland in recent years. In Iceland, MPH is available in 3 forms: immediate-release (IR) tablets (MPH IR, short-acting), sustainable-release (SR) capsules (MPH SR, long-acting) and osmotic-release (OROS) tablets (MPH OROS, long-acting). The aims of the study were to compare the pattern and subjective effects of i.v. MPH use to other i.v. psychostimulants and examine whether the pattern of use differs among MPH preparations. METHODS: This is a nationwide descriptive study. Information was collected from 95 i.v. substance users undergoing inpatient detoxification and reporting i.v. MPH use in the last 30 days using a semi-structured interview. RESULTS: MPH SR was both the most commonly used (96%) and preferred i.v. psychostimulant (57%). The intensity and duration of 'euphoria' did not differ between cocaine and MPH SR. No participant reported MPH OROS as their preferred substance even though a third had used it in the past month. CONCLUSIONS: The pattern of i.v. MPH use is similar to other psychostimulants among treatment seeking patients. MPH OROS was the least preferred i.v. psychostimulant, despite having the largest market share in Iceland. The results indicate that MPH OROS has less abuse potential than other MPH preparations.

Total population-based study of the impact of substance use disorders on the overall survival of psychiatric inpatients.

BACKGROUND: Patients with severe mental illness have a shortened lifespan, and substance use disorder (SUD) is an especially important diagnosis in this respect. There have been no studies comparing directly SUD to other diagnoses in a nationwide cohort. AIMS: To directly compare differences in mortality rates of psychiatric inpatients with a discharge diagnosis of SUD versus other psychiatric diagnoses. METHODS: A register-based study was made of all patients admitted to psychiatric hospitals in Iceland between 1983 and 2007. Patients were grouped according to discharge diagnoses. Survival with respect to SUD was compared using Cox-proportional hazard ratio, excluding those with an organic mental disorder. Furthermore, the survival of patients with SUD and co-morbid diagnoses was evaluated. RESULTS: A total of 14,281 patients (over the age of 18 years) were admitted to a psychiatric hospital in Iceland during the study period, with a total of 156,356 years of follow-up. For both men and women, a diagnosis of SUD conferred similar mortality as a diagnosis of schizophrenia without SUD, while individuals with a diagnosis of a mood disorder or "other disorders" had significantly lower mortality than SUD. For men with SUD, a co-occurring mental disorder was associated with an increased risk of dying, however, this was not found for women. CONCLUSIONS: SUD was the psychiatric diagnosis that had the highest mortality rate among psychiatric inpatients, in both men and women. An additional psychiatric diagnosis on a pre-existing SUD diagnosis did increase the risk for men but not women.

Mental disorder, imprisonment and reduced life expectancy--A nationwide psychiatric inpatient cohort study.

BACKGROUND: There is a strong correlation between severe mental illness and criminality, but little is known about how these two problem areas together may affect health outcomes. AIM: The objective of this paper is to compare survival rates of male psychiatric inpatients over a 25-year period who have and have not been subject to imprisonment, allowing for nature of psychiatric morbidity. METHODS: A nationwide cohort of men who had ever been psychiatric inpatients was identified from Icelandic data-registers, and their diagnoses after first discharge, cumulative incidence of imprisonment, and mortality established from records. Using a nested case-control design, survival differences were determined between those ever imprisoned and those never imprisoned. RESULTS: Between January 1983 and March 2008, 7665 men were admitted to psychiatric wards in Iceland, of whom 812 (10.6%) had served a prison sentence during that time. Cumulative incidence of imprisonment was highest in the youngest age group (21%). Substance use and personality disorders were more common amongst those imprisoned. All-cause mortality, adjusted for diagnosis, age, and year of admission, was twice as high amongst those imprisoned as those not imprisoned (Hazard ratio = 2.0, 95% CI 1.5-2.6, p < 0.001). CLINICAL IMPLICATIONS: Our findings indicate that psychiatric inpatients with criminal records should receive special attention with respect to all aspects of their health, not only within psychiatric services but also through more collaboration between the healthcare and judicial systems.

Swedish Version of Mood Spectrum Self-Report Questionnaire: Psychometric Properties of Lifetime and Last-week Version.

BACKGROUND: Mood Spectrum Self Report (MOODS-SR) is an instrument that assesses mood spectrum symptomatology including subthreshold manifestations and temperamental features. There are different versions of the MOODS-SR for different time frames of symptom assessment: lifetime (MOODS-LT), last-month and last-week (MOODS-LW) versions. OBJECTIVE: To evaluate the psychometric properties of the MOODS-LT the MOODS-LW. METHODS: The reliability of the MOODS-LT and MOODS-LW was evaluated in terms of internal consistency and partial correlations among domains and subdomains. The known-group validity was tested by comparing out-patients with bipolar disorder (n=27), unipolar depression (n=8) healthy controls (n=68). The convergent and divergent validity of MOODS-LW were evaluated using the Montgomery Åsberg Depression Rating Scale (MADRS), the Young-Ziegler Mania Rating Scale (YMRS) in outpatients as well the General Health Questionnaire (GHQ-12) in healthy controls. RESULTS: Both MOODS-LT and MOOODS-LW showed high internal consistency with the Kuder-Richardson coefficient ranging from 0.823 to 0.985 as well as consistent correlations for all domains and subdomains. The last-week version correlated significantly with MADRS (r= 0.79) and YMRS (r=0.46) in outpatients and with GHQ-12 (r= 0.50 for depression domain, r= 0.29 for rhythmicity) in healthy controls. CONCLUSION: The Swedish version of the MOODS-LT showed similar psychometric properties to other translated versions. Regarding MOODS-LW, this first published psychometric evaluation of the scale showed promising psychometric properties including good correlation to established symptom assessment scales. In healthy controls, the depression and rhythmicity domain scores of the last-week version correlated significantly with the occurrence of mild psychological distress.

A total population-based cohort study of female psychiatric inpatients who have served a prison sentence.

BACKGROUND: Studies of the overlap between severe mental disorder and criminality tend to focus on prison populations rather than psychiatric populations. AIMS: Our aims were to establish the prevalence of previous imprisonment among female psychiatric inpatients and test relationships between diagnoses, mortality and imprisonment. METHODS: A nationwide cohort of 18-65-year-old women who had been hospitalised for psychiatric disorder between January 1983 and March 2008 was identified from a hospital records database and linked to the database of the Prison and Probation Administration of Iceland as well as the National Register of causes of death at Statistics Iceland from January 1985. RESULTS: Six thousand and ninety-four women had had at least one psychiatric hospitalisation, 102 of them had been imprisoned on 172 occasions between them, giving an imprisonment rate of 118 per 100,000 over the 24 year period of study. The crude imprisonment proportion was 1.7% during a 20-year follow-up period; it was at its peak (5%) among 18-30 year-olds at index admission. Substance use and personality disorders were the most common diagnoses associated with imprisonment. Mortality rates were not statistically different between those imprisoned and not (hazard ratio = 1.3, 95% confidence interval 0.5-3.5). CONCLUSION AND IMPLICATIONS FOR PRACTICE: Women admitted to a psychiatric hospital have higher rates of imprisonment than the general population. Because admission predated imprisonment in most cases, this may be seen as an opportunity for early intervention to reduce later criminality.

[Online quizzes for practice and assessment of pharmacotherapeutic knowledge during clinical courses in medical school - a pilot study in the psychiatry and neurology courses]. / Webbaserade quiz om läkemedel för övning och examination.

In this study, we developed auto-graded quizzes for practice and for summative assessment, covering drugs of relevance in the undergraduate clinical psychiatry and neurology courses in medical school. The underlying intention was to combine repetition of theoretical aspects and promoting progression to the clinical context. The quizzes were implemented in two steps. After the courses in question were completed, before and after the first as well as the second step of quiz implementation, the students' achieved level of knowledge was investigated by a voluntary formative test/questionnaire including 20 patient-based single best answer questions. In the first step, voluntary practice quizzes and a summative assessment test were introduced. In the second step, a clinical context was provided to the quizzes, using the structure of the practical manual to good prescribing issued by the World Health Organization in 1994. Furthermore, the summative test was expanded for improved constructive alignment, exposing the students to the drug-related course content to a greater extent. In all, 274 students out of 404 participated in the study (response rate: 68%; 56% women; 66% ≤24 years). Compared with before the quiz implementation (median number of correct answers: 10 [interquartile range: 9-13]), no difference was seen after the first step (11 [8-13]; P=0.88) but a clear improvement appeared after the second step (14 [12-16]; P<0.0001). After the second step, the students reported having used all (17%), most (22%), some (32%), or no (29%) practice quizzes. The extent of use was positively correlated with the number of correct answers in the formative test (r=0.33; P=0.002). After the second step, the student-reported number of attempts at the assessment quiz was in median 6 times (interquartile range: 3-9). There was a negative correlation between the number of quiz attempts and the extent of use of practice quizzes (r=-0.22; P=0.034) as well as the number of correct answers in the formative test (r=-0.44; P<0.0001). In conclusion, practice and assessment quizzes about drugs, elaborated with clinical context and constructive alignment, may increase pharmacotherapeutic knowledge in medical students.

Usability Comparison Among Healthy Participants of an Anthropomorphic Digital Human and a Text-Based Chatbot as a Responder to Questions on Mental Health: Randomized Controlled Trial.

BACKGROUND: The use of chatbots in mental health support has increased exponentially in recent years, with studies showing that they may be effective in treating mental health problems. More recently, the use of visual avatars called digital humans has been introduced. Digital humans have the capability to use facial expressions as another dimension in human-computer interactions. It is important to study the difference in emotional response and usability preferences between text-based chatbots and digital humans for interacting with mental health services. OBJECTIVE: This study aims to explore to what extent a digital human interface and a text-only chatbot interface differed in usability when tested by healthy participants, using BETSY (Behavior, Emotion, Therapy System, and You) which uses 2 distinct interfaces: a digital human with anthropomorphic features and a text-only user interface. We also set out to explore how chatbot-generated conversations on mental health (specific to each interface) affected self-reported feelings and biometrics. METHODS: We explored to what extent a digital human with anthropomorphic features differed from a traditional text-only chatbot regarding perception of usability through the System Usability Scale, emotional reactions through electroencephalography, and feelings of closeness. Healthy participants (n=45) were randomized to 2 groups that used a digital human with anthropomorphic features (n=25) or a text-only chatbot with no such features (n=20). The groups were compared by linear regression analysis and t tests. RESULTS: No differences were observed between the text-only and digital human groups regarding demographic features. The mean System Usability Scale score was 75.34 (SD 10.01; range 57-90) for the text-only chatbot versus 64.80 (SD 14.14; range 40-90) for the digital human interface. Both groups scored their respective chatbot interfaces as average or above average in usability. Women were more likely to report feeling annoyed by BETSY. CONCLUSIONS: The text-only chatbot was perceived as significantly more user-friendly than the digital human, although there were no significant differences in electroencephalography measurements. Male participants exhibited lower levels of annoyance with both interfaces, contrary to previously reported findings.

Transcutaneous auricular vagus nerve stimulation to acutely reduce emotional vulnerability and improve emotional regulation in borderline personality disorder (tVNS-BPD): study protocol for a randomized, single-blind, sham-controlled trial.

BACKGROUND: Borderline personality disorder (BPD) is considered a disorder of emotion regulation resulting from the expression of a biologically determined emotional vulnerability (that is, heightened sensitivity to emotion, increased emotional intensity/reactivity, and a slow return to emotional baseline) combined with exposure to invalidating environments. Vagal tone has been associated with activity in cortical regions involved in emotion regulation and a lower resting state of vagal tone has been observed in BPD patients relative to healthy controls. Non-invasive transcutaneous auricular vagus nerve stimulation (taVNS) has been shown to reduce temper outbursts in adults with Prader-Willi Syndrome, to enhance recognition of emotions in healthy students, and to improve depressive and anxiety symptoms. Furthermore, a single session of taVNS has been shown to acutely alter the recognition of facial expressions of negative valence in adolescents with MDD and increase emotion recognition in controls. However, the effect of taVNS on emotional vulnerability and regulation in individuals diagnosed with BPD has not been investigated. Our aims are to determine if taVNS is effective in acutely reducing emotional vulnerability and improve emotional regulation in BPD patients. METHODS: Forty-two patients will be randomized to a single session of taVNS or sham-taVNS while going through an affect induction procedure. It will consist of the presentation of one neutral and three negative affect-evoking 4-min-long videos in sequence, each of which is followed by a 4-min post-induction period during which participants will rate the quality and intensity of their current self-reported emotions (post-induction ratings) and the perceived effectiveness in managing their emotions during the video presentation. The rating of the current self-reported emotions will be repeated after every post-induction period (recovery ratings). Mixed models with individuals as random effect will be used to investigate the ratings at each stage of the study, taking into account the repeated measures of the same individuals at baseline, pre-induction, post-induction, and recovery. DISCUSSION: The study has potential to yield new insights into the role of vagal tone in emotion dysregulation in BPD and offer preliminary data on the effectiveness of taVNS as a possible non-invasive brain stimulation to treat a core symptom of BPD. TRIAL REGISTRATION: ClinicalTrials.gov NCT05892900. Retrospectively registered on Jun 07, 2023.

Patient Experience of Digitalized Follow-up of Antidepressant Treatment in Psychiatric Outpatient Care: Qualitative Analysis.

BACKGROUND: Nonadherence to pharmaceutical antidepressant treatment is common among patients with depression. Digitalized follow-up (ie, self-monitoring systems through mobile apps) has been suggested as an effective adjunct to conventional antidepressant treatment to increase medical adherence, improve symptoms of depression, and reduce health care resource use. OBJECTIVE: The aim of this study was to determine patients' experience of digitalized follow-up using a mobile app as an adjunct to treatment concurrent with a new prescription, a change of antidepressant, or a dose increase. METHODS: This was a qualitative, descriptive study. Patients at 2 psychiatric outpatient clinics were recruited at the time of changing antidepressant medication. After using a mobile app (either a commercial app or a public app) for 4-6 weeks with daily registrations of active data, such as medical intake and questions concerning general mental health status, individual semistructured interviews were conducted. Recorded data were transcribed and then analyzed using content analysis. RESULTS: In total, 13 patients completed the study. The mean age was 35 (range 20-67) years, 8 (61.5%) were female, and all reported high digital literacy. Overall, the emerging themes indicated that the patients found the digital app to be a valuable adjunct to antidepressant treatment but with potential for improvement. Both user adherence and medical adherence were positively affected by a daily reminder and the app's ease of use. User adherence was negatively affected by the severity of depression. The positive experience of visually presented data as graphs was a key finding, which was beneficial for self-awareness, the patient-physician relationship, and user adherence. Finally, the patients had mixed reactions to the app's content and requested tailored content. CONCLUSIONS: The patients identified several factors addressing both medical adherence and user adherence to a digital app when using it for digitalized follow-up concurrent with the critical time related to changes in antidepressant medication. The findings highlight the need for rigorous evidence-based empirical studies to generate sustainable research results.

Approaching "highly sensitive person" as a cultural concept of distress: a case-study using the cultural formulation interview in patients with bipolar disorder.

Background: Psychiatric patients may refer to concepts neither medically accepted nor easily understood to describe their experiences when seeking medical care. These concepts may lie outside the clinician's cultural references and consequently hinder the diagnostic consultation. In the fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the clinical instrument Cultural Formulation Interview (CFI) was included. The CFI aims to facilitate the gathering and synthesis of culturally relevant clinical information. The notion of Cultural Concepts of Distress (CCD) was also introduced in DSM-5. The CCD include the subterms of the cultural syndrome, cultural explanation, and cultural idiom of distress. No previous study has used CFI for conceptualizing a cultural notion as a CCD. This study aimed to approach the cultural notion of being a highly sensitive person (HSP) in patients with bipolar disorder (BD) by applying the CFI. The cultural notion of HSP has garnered great interest globally, although scientific evidence is limited. No direct correlation between BD and HSP was hypothesized before or during the study process. Methods: In this case study, three patients with BD who reported being HSP were interviewed using the CFI. Furthermore, the applicability of the CCD was examined based on the outcomes of the CFI using an interpretive approach. Results: All three patients reported that the CFI facilitated the clinical consultation, and in one of the cases, it may also have increased the treatment engagement. Based on the synthesis of the CFI outcomes in these illustrative cases, HSP could be understood as a cultural syndrome, a cultural explanation, and a cultural idiom of distress. Conclusion: By applying a person-centered perspective, CFI was used for the conceptualization of a cultural notion as a CCD (i.e., HSP in our study). Moreover, the cases highlight the complexity of illness insight in BD as a medical phenomenon when patients' illness perspectives are taken into consideration. Future studies need to further examine the clinical relevance of the CFI in the management of BD.

The low risk for early renal damage during lithium treatment has not changed over time.

BACKGROUND: Modern lithium management guidelines were introduced to improve the renal prognosis of lithium patients. AIMS: To examine whether prospects for severe renal impairment (defined as chronic kidney disease at least stage 4 (CKD4)), in long-term lithium patients, have changed over time after the introduction of lithium monitoring guidelines. METHODS: The time to and hazard for CKD4 were compared between three patient cohorts who started long-term lithium in three consecutive decades: 1980s, 1990s and 2000s. The follow-up time was 10 years after completion of 1-year treatment. The data were collected from Sahlgrenska University Hospital's laboratory database. RESULTS: In all, 2169 patients were included: 623 in Cohort 1 (started lithium during 1980s), 874 in Cohort 2 (1990s) and 672 in Cohort 3 (2000s). Compliance with lithium monitoring guidelines improved, and mean serum lithium decreased, through the cohorts. In all, 22 patients developed CKD4 during follow-up. The time to CKD4 was the same in all three cohorts (overall: 10.96 years, 95% confidence interval: 10.94-11 years). Age and serum creatinine concentration at start were significant risk factors, while sex had no prognostic value. After adjusting for the significant covariates, there was no statistically significant difference in the hazard for CKD4 between the three cohorts. CONCLUSION: The risk for severe renal damage during the first decade of long-term lithium is low, but has not changed over time. Our data suggest that improved compliance with lithium guidelines is not reflected in less risk for severe renal damage.