A protocol for a pilot randomised controlled trial of an Early Psychiatric Assessment, Referral, and Intervention Study (EPARIS) for intensive care patients.

BACKGROUND: Up to 80% of Intensive Care Unit patients experience physical, cognitive, and/or psychological complications post-discharge, known as 'Post Intensive Care Syndrome' (PICS). Early diagnosis and intervention are a priority, but while current post-intensive care follow-up processes endorse a multidisciplinary model, incorporating a psychiatric consultation has not been studied. METHODS: A pilot, open-label randomised controlled trial was developed by a multidisciplinary team to evaluate the feasibility and acceptability of incorporating a psychiatric review into an existing post-ICU clinic. The study will run for 12 months and aim to recruit 30 participants. Inclusion criteria for participants: a) ICU admission greater than 48 hours, b) no cognitive impairment that prevents participation, c) ≥ 18 years old, d) residing in Australia, e) fluent in English, f) able to provide GP information, and g) likely to be contactable in 6 months. Patient recruitment will be at Redcliffe Hospital, Queensland, Australia, and will involve patients attending the Redcliffe post intensive care clinic. Participants will be allocated to intervention or control using block randomisation and allocation concealment. Participants allocated to the control arm will receive the standard cares provided by the clinic, which involves an unstructured interview about their ICU experience and a battery of surveys about their psychological, cognitive, and physical function. Those allocated to the intervention arm will receive these same cares as well as an appointment with a psychiatrist for a single session intervention. The psychiatric intervention will involve a comprehensive review, including comorbid disorders, substance use, suicidal ideation, psychosocial stressors, social/emotional supports. Psychoeducation and initial treatment will be provided as indicated and recommendations given to the patient and their GP about how to access ongoing care. In addition to surveys conducted as part of standard clinic cares, all participants will complete additional questionnaires about their history, hospital experience, mental and physical health as well as employment circumstances. All participants will be followed up 6 months after their appointment and will be invited to complete follow-up questionnaires about their mental and physical health, as well as health service use and employment circumstances. The trial has been registered with ANZCTR (ACTRN12622000894796). RESULTS: To evaluate the feasibility and acceptability of the intervention to the patient population. Differences between groups will be assessed using an independent samples t-test. Resource requirements to administer the intervention will be evaluated by reporting the mean duration of the EPARIS assessment and approximate cost per patient to provide this service. To estimate the effect size of any treatment effects, changes in secondary outcome measures between baseline and 6 months will be compared between intervention and control groups using Analysis of Covariance regression. As this is a pilot, we will not use p-values or test a null hypothesis, but will give confidence intervals. CONCLUSIONS: This protocol provides a pragmatic evaluation of the acceptability of introducing early psychiatric assessment into an existing post-ICU follow-up process, and if considered acceptable will inform future research into the efficacy and generalisability of the intervention. The strengths of EPARIS are the prospective, longitudinal design with a control population, and its use of validated post-ICU outcome measures.

Ambulatory assessment to predict problem anger in trauma-affected adults: Study protocol.

BACKGROUND: Problem anger is common after experiencing a traumatic event. Current evidence-driven treatment options are limited, and problem anger negatively affects an individual's capacity to engage with traditional psychological treatments. Smartphone interventions hold significant potential in mental health because of their ability to deliver low-intensity, precision support for individuals at the time and place they need it most. While wearable technology has the capacity to augment smartphone-delivered interventions, there is a dearth of evidence relating to several key areas, including feasibility of compliance in mental health populations; validity of in vivo anger assessment; ability to predict future mood states; and delivery of timely and appropriate interventions. METHODS: This protocol describes a cohort study that leverages 10 days of ambulatory assessment in the form of ecological momentary assessment and a wearable. Approximately 100 adults with problem anger will complete four-hourly in vivo mobile application-delivered micro-surveys on anger intensity, frequency, and verbal and physical aggression, as well as other self-reported mental health and wellbeing measures. Concurrently, a commercial wearable device will continuously record indicators of physiological arousal. The aims are to test the feasibility and acceptability of ambulatory assessment in a trauma-affected population, and determine whether a continuously measured physiological indicator of stress predicts self-reported anger intensity. DISCUSSION: This study will contribute new data around the ability of physiological indicators to predict mood state in individuals with psychopathology. This will have important implications for the design of smartphone-delivered interventions for trauma-affected individuals, as well as for the digital mental health field more broadly.

Using an ecological momentary assessment protocol to understand problem anger in veterans.

BACKGROUND AND OBJECTIVES: Problem anger is highly destructive, and is one of the most commonly reported issues in military and veteran populations. The goal of this study was to use ecological momentary assessment (EMA) to explore and characterize moment-to-moment experiences of problem anger in a sample of Australian veterans. METHODS: Sixty veterans with problem anger (measured on the Dimensions of Anger Reactions Scale) completed measures of anger and anger rumination, before and after a 10-day EMA period which assessed the frequency, intensity, and expression of momentary anger experiences. RESULTS: Findings showed that 75% of respondents indicated some level of anger during EMA monitoring. In 25% of cases, anger was reported as severe. Moreover, anger was expressed verbally in 43% of cases, and expressed physically in 27% of cases. While anger fluctuated frequently during the day, more severe anger was more likely to be reported in the late afternoon/early evening. Problem anger symptoms decreased significantly over time, from pre-EMA to post EMA (p < .001). LIMITATIONS: The generalizability of findings is limited to a predominantly male sample, with low levels of risk of harm or violence. The study was also limited in the selection of outcome variables assessed and the lack of a control group; other momentary factors could influence experience of problem anger and provide further explanation of study results. CONCLUSIONS: EMA is a valuable assessment tool for individuals with problem anger, and the potential for EMA as an intervention needs to be explored further.

What Are Effective Psychological Interventions for Veterans With Sleep Disturbances? A Rapid Evidence Assessment.

BACKGROUND: Insomnia and related sleep disturbances commonly occur in veterans, with prevalence rates as high as 90% reported in some studies. Military-specific factors such as sleep disturbances during military training and deployment, as well as a higher prevalence of post-traumatic stress disorder (PTSD), which is known to poorly impact sleep, may contribute to higher insomnia rates in veterans. Although evidence-based guidelines for the treatment of insomnia exist, the unique nature of veterans sleep problems means they may differ in their response to treatment. The aim of this study was to review the evidence for interventions for veterans with sleep disturbances. METHODS: This literature review used a rapid evidence assessment methodology, also known as rapid review. The rapid evidence assessment methodology involves rigorously locating, appraising, and synthesising the evidence while making concessions to the breadth or the depth of the process in order to significantly decrease the length of the process. EMBASE, MEDLINE (PubMed), PsychINFO, Cochrane, Clinical Guidelines Portal (Australia), and the National Guideline Clearinghouse (United States) were searched for peer-reviewed literature and guidelines published from 2004 to August 2015 that investigated psychological interventions for veterans with sleep disturbances. The literature was assessed in terms of strength (quality, quantity, and level of evidence), direction, and the consistency, generalizability, and applicability of the findings to the population of interest. These assessments were then collated to determine an overall ranking of level of support for each intervention: "Supported" (clear, consistent evidence of a beneficial effect), "Promising" (evidence suggestive of a beneficial effect but further research is required), "Unknown" (insufficient evidence of beneficial effect and further research is required), and "Not Supported" (clear consistent evidence of no effect or negative harmful effect). FINDINGS: From an initial yield of 1,131 articles, 18 studies met the inclusion criteria for review. The majority of the studies investigated the effectiveness of cognitive behavioral therapy for insomnia (CBTi; n = 10). Five studies investigated CBTi with an adjunctive psychotherapy, typically for PTSD-related sleep disturbances. One further study investigated sleep hygiene education (a component of CBTi) with pharmacotherapy. Two final studies investigated hypnotherapy and mind-body bridging, respectively. Overall, the quality of the studies was mixed, with some high and some poor quality studies. DISCUSSION: There was sufficient evidence to support CBTi with adjunctive psychotherapy for veterans with PTSD-related sleep disturbances, although the evidence for CBTi in the treatment of general sleep disturbance for veterans was ranked as "promising." This indicates a beneficial effect, but more research is needed to confidently establish efficacy in a veteran population. There is currently insufficient evidence to support the use of sleep hygiene education and pharmacotherapy, hypnotherapy, or mind-body bridging. Further research dismantling the components of CBTi is needed to identify which are the critical components. Such research has the potential to lead to brief, targeted, and accessible treatments that overcome the time and stigma-related barriers to care that veterans often face.