Traumatic imagery following glucocorticoid administration in earthquake-related post-traumatic stress disorder: A preliminary functional magnetic resonance imaging study.

OBJECTIVE: Post-traumatic stress disorder involves excessive retrieval of traumatic memories. Glucocorticoids impair declarative memory retrieval. This preliminary study examined the effect of acute hydrocortisone administration on brain activation in individuals with earthquake-related post-traumatic stress disorder compared with earthquake-exposed healthy individuals, during retrieval of traumatic memories. METHOD: Participants exposed to earthquakes with (n = 11) and without post-traumatic stress disorder (n = 11) underwent two functional magnetic resonance imaging scans, 1-week apart, in a double-blind, placebo-controlled, counter-balanced design. On one occasion, they received oral hydrocortisone (20 mg), and on the other, placebo, 1 hour before scanning. Symptom provocation involved script-driven imagery (traumatic and neutral scripts) and measures of self-reported anxiety. RESULTS: Arterial spin labelling showed that both post-traumatic stress disorder and trauma-exposed controls had significantly reduced cerebral blood flow in response to retrieval of traumatic versus neutral memories in the right hippocampus, parahippocampal gyrus, calcarine sulcus, middle and superior temporal gyrus, posterior cingulate, Heschl's gyrus, inferior parietal lobule, angular gyrus, middle occipital gyrus, supramarginal gyrus, lingual gyrus and cuneus, and the left prefrontal cortex. Hydrocortisone resulted in non-significant trends of increasing subjective distress and reduced regional cerebral blood flow in the left inferior frontal gyrus, left anterior cingulate gyrus, middle temporal gyrus, cerebellum, postcentral gyrus and right frontal pole, during the trauma script. CONCLUSION: Findings do not fit with some aspects of the accepted neurocircuitry model of post-traumatic stress disorder, i.e., failure of the medial prefrontal cortex to quieten hyperresponsive amygdala activity, and the potential therapeutic benefits of hydrocortisone. They do, however, provide further evidence that exposure to earthquake trauma, regardless of whether post-traumatic stress disorder eventuates, impacts brain activity and highlights the importance of inclusion of trauma-exposed comparisons in studies of post-traumatic stress disorder.

Clinical response to treatment in inpatients with depression correlates with changes in activity levels and psychomotor speed.

BACKGROUND: Monitoring clinical response to treatment in depressed inpatients, particularly identifying early improvement, may be sub-optimal. This may impact adversely on patients through longer admissions and sub-optimal pharmacotherapy. Psychomotor speed is a prominent neuropsychological function which changes as recovery occurs. This study examines simple techniques used to quantify psychomotor change and their potential to contribute to monitoring recovery. METHODS: Activity levels were continuously monitored in patients diagnosed with a major depressive episode from four acute psychiatric wards using two actigraphs (commercial and scientific) for 3 weeks and linear regression used to calculate a gradient to express rate of change. Psychomotor speed was assessed using the simple Coin Rotation Task. Mood and functioning were rated using the Quick Inventory of Depressive Symptoms, Clinical Global Impression Scale and Functioning Assessment Short Test. The assessments were completed at baseline and follow-up (3 weeks), and correlations were calculated for all change measures. RESULTS: In all, 24 inpatients were recruited but not all completed baseline and follow-up measures. Change in activity count ( N = 16) and psychomotor speed ( N = 13) correlated significantly with improvement in clinical measures of depressive symptoms. Actigraphs were acceptable to hospital inpatients. LIMITATIONS: The limited size of this pilot study precludes the analysis of predictive power or the influence of other variables such as depression subtypes, age, gender or variations related to medications. CONCLUSION: Early change in simple activity and psychomotor speed warrant further investigation for utility in measuring treatment response in depressed inpatients.

Self-management for bipolar disorder and the construction of the ethical self.

The promotion of the self-managing capacities of people has become a marker of contemporary mental health practice, yet self-management remains a largely uncontested construct in mental health settings. This discourse analysis based upon the work of Foucault investigates self-management practices for bipolar disorder and their action upon how a person with bipolar disorder comes to think of who they are and how they should live. Using Foucault's framework for exploring the ethical self and transcripts of interviews with people living with bipolar disorder, this discourse analysis finds that the discursive practices of self-management for bipolar disorder are prescribing a restricted regime for living based upon the quintessential neo-liberal subject using practices that are focused upon managing an unreliable and problematic self. The article concludes with the proposition that the problem of bipolar disorder (for which self-management is an answer) is less about the object itself and more about how we construct the nature of the self. A Maori indigenous ontology is used here as an example of an alternative discursive resource through which people make sense of the self and which allows ways of thinking about self-management that engage with ambivalence and ambiguity rather than restriction and regulation.

Effectiveness of interventions to improve medication adherence in bipolar disorder.

OBJECTIVE: To identify interventions that improve medication adherence in bipolar disorder. METHOD: A review of the literature from 2004 to 2011 was conducted using Medline and manual searching. RESULTS: Eleven studies were identified as meeting inclusion criteria. Five studies demonstrated improved medication adherence. No characteristics of the interventions, clinical characteristics of the groups or methodological factors distinguished those psychosocial interventions that demonstrated improvement from those that did not. CONCLUSIONS: While only a few interventions improved adherence, most improved clinical outcomes. Issues were also identified about the way in which adherence is defined. It is proposed that incorporating patient preferences into measures of adherence within the context of a disorder-specific psychosocial intervention may provide an approach that demonstrates both improved adherence and improved clinical outcomes. However this requires further research.

Health professional perspectives on translation of cultural safety concepts into practice: A scoping study.

People from unique and diverse populations, (i.e., social groupings excluded by the dominant majority by, for example, ethnicity, gender, age, sexual orientation, disability or even rurality), experience dissimilar health outcomes. Members of such populations who have long-term health conditions experience further health disparities through inefficient management and treatment. This remains a significant hindrance to achieving equity in health outcomes. Being responsive and acting upon the cultural needs of unique and diverse populations within health services is pivotal in addressing health disparities. Despite provision of professional training to health professionals, cultural competency remains an elusive goal. This scoping study summarized available literature about what helped health professionals translate cultural safety concepts into practice. We searched electronic databases using MeSH terms and keywords for English language articles and reference lists of potentially included studies. Quality appraisal was undertaken using Joanna Briggs Institute critical appraisal tools. Data were charted, with a descriptive numerical summary and thematic analysis of study findings undertaken. Twelve qualitative studies with n = 206 participants were included. Learning through and from direct experience, and the individual qualities of professionals (i.e., individual capacity for relational skills and intentionality of engagement with one's own values and biases) facilitated translation of cultural safety concepts into practice. Also important was the need for cultural training interventions to address both issues of content and process within course design. Doing this would take into consideration the benefits that can come from learning as a part of a collective. In each of these themes was evidence of how health professionals needed the ability to manage emotional discomfort as part of the process of learning. A dearth of information exists exploring professionals' perspectives on translating cultural safety concepts into practice. There may be merit in designing educational interventions that look beyond the classroom. We also suggest that nurturing people's relational skills likely holds benefits to growing culturally safe practice as does increasing health professional's capacity to sit with the discomfort that occurs when paying attention to one's own and others values and biases.

Learning to live well with chronic fatigue: the personal perspective.

BACKGROUND: Persistent fatigue is recognized as an integral and significantly disabling aspect of the experience of living with a long-term health condition. Acute medical care models have limited applicability when seeking to provide health care to meet the needs of those living with chronic fatigue. AIMS: This article is a report of a study that sought to understand how people can live well in spite of the presence of chronic fatigue. METHODS: A thematic analysis was conducted on 43 narratives provided by people living with chronic fatigue during 2007 as part of an internet-based study. FINDINGS: This report focuses on the two themes that appeared of most relevance to participants: managing energy and redefining self. Two particular approaches to energy management were noted. In the first, the focus is upon moderating and avoiding excess to manage energy. In the second approach, the body was conceptualized as a machine so that energy becomes a limited resource to be managed. Work to redefine the sense of self appeared to be focused upon the desire to seek normality, to see oneself as rational and come to terms with change. CONCLUSION: People can and do find ways to live well with chronic fatigue. Understanding how the person with chronic fatigue has come to conceptualize his/her experiences will be a more fruitful starting point than providing recipes for successful living if nurses are to work effectively with this group of people.

Valued identities and deficit identities: Wellness Recovery Action Planning and self-management in mental health.

Wellness Recovery Action Planning (WRAP) is a self-management programme for people with mental illnesses developed by a mental health consumer, and rooted in the values of the 'recovery' movement. The WRAP is noteworthy for its construction of a health identity which is individualised, responsibilized, and grounded in an 'at risk' subjectivity; success with this programme requires development of an intensely focused health lifestyle. We draw on Bourdieu and Giddens to argue that what is being developed is a 'reflexive health habitus', which is not equally accessible to all social groups, and is in tension with WRAP's recovery-orientated aims. However, it is understandable that such a programme developed in mental health, because people with mental illness are highly stigmatized as 'a risk' and viewed as in need of risk management. By developing their own form of self-monitoring 'at risk' identity, mental health consumers are, paradoxically, able to construct themselves as ideal health citizens and no longer a risk, thus re-entering the moral community. We conclude by suggesting some changes to WRAP practice.

Parenting with a diagnosis bipolar disorder.

AIM: This paper is a report of a study of the ways in which bipolar disorder is constructed in the DSM-IV and popular texts, and how parents who have been diagnosed as having a bipolar disorder construct their role as parent. BACKGROUND: Research into parenting and mental illness has typically taken a deficit-based approach that focuses on the risks to children when a parent has a mental illness. Literature that considers parenting specifically in the context of bipolar disorder retains a focus on the increased risk to their children of psychopathology or psychosocial difficulties. METHOD: A critical discourse analysis was conducted using interviews with five parents who had received a diagnosis of bipolar disorder. These interviews were examined in relation to the text that constructs the diagnosis of bipolar disorder (DSM-IV) and the popular texts from which the parents drew their understandings of parenting. FINDINGS: The need to monitor and moderate emotions was a dominant theme that emerged from the analysis. For these parents this also involved teaching moderation to their children and monitoring it in their children's development. The consequence of this for these parents was a heightened sense of the need for self-surveillance. CONCLUSION: The challenge for people working with parents who have been diagnosed with a bipolar disorder is to support them to feel confident in the management of their bipolar disorder and their ability to parent effectively.

Psychoeducation for bipolar disorder: A discourse analysis.

Psychoeducation has become a common intervention within mental health settings. It aims to increase people's ability to manage a life with a long-term illness. For people with bipolar disorder, psychoeducation is one of a range of psychosocial interventions now considered part of contemporary mental health practice. It has taken on a 'common sense' status that results in little critique of psychoeducation practices. Using a published manual on psychoeducation and bipolar disorder as its data, Foucauldian discourse analysis was used in the present study for a critical perspective on psychoeducation in order to explore the taken-for-granted assumptions on which it is based. It identifies that the text produces three key subject positions for people with bipolar disorder. To practice self-management, a person must: (i) accept and recognize the authority of psychiatry to know them; (ii) come to see that they can moderate themselves; and (iii) see themselves as able to undertake a reflexive process of self-examination and change. These findings highlight the circular and discursive quality to the construct of insight that is central to how psychoeducation is practiced. Using Foucault's construct of pastoral power, it also draws attention to the asymmetrical nature of power relations between the clinician and the person with bipolar disorder. An effect of the use of medical discourse in psychoeducation is to limit its ability to work with ambivalence and contradiction. A critical approach to psychotherapy and education offers an alternate paradigm on which to basis psychoeducation practices.

Patients' reports of the factors influencing medication adherence in bipolar disorder - an integrative review of the literature.

BACKGROUND: As with other long-term conditions patients with bipolar disorder are rarely totally adherent or non-adherent. Rates of non-adherence have not changed since the first introduction of psychotropic medications in the 1950s despite vast numbers of new compounds being marketed. Non-adherence with medication in bipolar disorder is associated with affective relapse and consequently poor quality of life. The reasons that patients are non-adherent with medication are not well understood by clinicians who often assume it is related to the illness itself. OBJECTIVES: To identify patients' perceptions of medication adherence in bipolar disorder. DESIGN: An integrated review of the literature published between 1999 and 2010. DATA SOURCES: Ovid (Medline, CINAHL, Embase, PsycINFO) and manual searching. REVIEW METHODS: An integrative review of the literature was conducted which included: (a) problem formation, (b) literature search and initial screening, (c) gathering data from studies, (d) evaluating study quality, (e) data analysis and integration, (f) data interpretation, and (g) presentation of the findings. RESULTS: Thirteen articles met criteria for inclusion in the review. These articles identified how patients reported their perceptions on medication and were integrated into four categories: illness factors, personal attitudes and beliefs, medication factors and environmental factors. CONCLUSIONS: These findings suggest a need to address adherence from the full range of influencing factors (patient, illness, medication and environmental). Clinicians need to utilise a collaborative approach to working together with patients in order to identify the meaning that patients attribute to the symptoms, diagnosis, prognosis and medication. Understanding patients' perceptions and accepting these may facilitate greater medication adherence and the consequent improved clinical outcomes for patients with bipolar disorder.

Disorder-specific psychosocial interventions for bipolar disorder--a systematic review of the evidence for mental health nursing practice.

AIMS: To systematically review the evidence for the efficacy of psychosocial interventions for bipolar disorder and examine the implications for mental health nursing practice. BACKGROUND: Bipolar disorder is associated with significant psychosocial impairment and high use of mental health services. Generally medication is effective in the treatment of acute episodes but there is increasing evidence that while a large majority of patients recover from these episodes of mania and/or depression, many do not achieve a functional recovery. In response a range of psychotherapies have either been adapted or developed. DESIGN: An extensive review of the literature was performed using Medline, Cinahl and PsycINFO databases and 35 relevant research studies were chosen that met inclusion criteria. FINDINGS: All the identified psychosocial interventions were structured, adhered to manualized protocols and had solid evidence demonstrating their effectiveness when used as an adjunct to psychopharmacology. The identified psychosocial interventions all incorporated some features of a psycho-education including developing an acceptance of the disorder, awareness of its prodromes and signs of relapse, and communication with others; and several emphasise regular sleep and activity habits. CONCLUSION: Mental health nurses have an important role to play in integrating psychosocial interventions into their clinical practice settings and in conducting high quality trials of their clinical effectiveness. Nurses are well-positioned to lead pragmatic trials of the clinical effectiveness of these psychosocial interventions in mental health services because of their experience and expertise in working with patients with bipolar disorder.