Pilot randomized controlled trial of biofeedback on reducing psychological and physiological stress among persons experiencing homelessness.

People experiencing homelessness report increased exposure to traumatic life events and higher rates of depression, anxiety, and post-traumatic stress disorder as compared with the general population. Heart rate variability-biofeedback (HRV-BF) has been shown to decrease symptoms of stress, anxiety, depression, and PTSD. However, HRV-BF has not been tested with the most vulnerable of populations, homeless adults. The purpose of this randomized controlled trial was to compare the effectiveness of an HRV-BF intervention versus a Health Promotion (HP) active control intervention focused on improving mental health symptoms among homeless adults. Guided by a community advisory board, homeless adults residing in Skid Row, Los Angeles (n = 40) were randomized to either the HRV-BF or an active HP control group and received eight weekly, 30-min sessions over two months, delivered by a nurse-led community health worker team. Dependent variables of HRV, mental health, anxiety, depression, and PTSD were measured at baseline, the 8-week session, and/or 2-month follow-up. All intervention sessions were completed by 90% (36/40) of participants. Both the HRV-BF and HP interventions showed significant increases in HRV from baseline to 2-month follow-up, with no significant difference between the intervention groups. The HRV-BF programme revealed a somewhat greater, although non-significant, improvement in anxiety, depression, and PTSD symptoms than the HP programme. The usefulness of both interventions, focused on emotional and physical health, warrants future studies to examine the value of a combined HRV-BF and HP intervention.

A Preliminary Test of the Efficacy of Brief Self-Administered Behavioral Interventions for Rumination.

Rumination is theorized to be a cognitive avoidance process that is implicated in several manifestations of psychopathology. Few interventions directly target rumination as a core process maintaining emotional disorder symptoms. This pilot study compared the feasibility and preliminary efficacy of self-directed behavioral approaches for reducing rumination. Participants (N = 60) with elevations in rumination were randomized to 3 weeks of self-directed interventions: (a) scheduled rumination time; (b) a strategy combining mindfulness, shaping, and disengagement strategies; or (c) self-monitoring control. Both active treatment conditions outperformed self-monitoring control on post-treatment depression scores. Scheduled rumination time significantly outperformed the other two conditions on measures of rumination and worry. No between-group differences emerged on the secondary outcome (i.e., anxiety symptoms). Brief, self-directed, behavioral interventions targeting rumination are feasible and demonstrate preliminary efficacy. Scheduled rumination time shows moderate to large effects. The use of a small, non-treatment seeking sample was the primary limitation.

Development of a First Peoples-led cultural capability measurement tool: A pilot study with midwifery students.

BACKGROUND: Midwives have a central role in closing the gap in health inequalities between Australias' First Peoples and other childbearing women. The Aboriginal and Torres Strait Islander Health Curriculum Framework (The Framework) identifies five core cultural capabilities (respect, communication, safety and quality, reflection and advocacy) to foster culturally safe health care. AIM: To use a decolonising, First Peoples-led approach to develop and validate a tool to measure the development students' cultural capabilities. METHOD: A pre- post intervention design was used. Development of the Cultural Capability Measurement Tool followed a staged process which centred on First Peoples' knowledges. This process included: item generation, expert review; a pilot, test-retest; and psychometric testing (reliability, factor analysis and construct validity). All third year midwifery students (n=49) enrolled in a discrete First Peoples health course were invited to complete the survey pre and post course. FINDINGS: A response rate of 77.5% (n=38/49) pre-course and 30.6% (15/49) at post-course was achieved. The tool demonstrated good internal reliability (Cronbach alpha=.89-.91). Principal component analysis with varimax rotation produced a five-factor solution. A paired samples t-test revealed a significant increase from pre-course (mean 93.13, SD 11.84) to post-course scores (mean=100.53, SD 7.54) (t (14)=-2.79, p=.014). CONCLUSION: A First Peoples approach was critical to tool development and conceptual validity. The 22 item Cultural Capability measurement Tool reflected the core cultural capabilities of The Framework. The draft tool appears suitable for use with midwifery students.

Randomized controlled trial of cognitive behavioral therapy and acceptance and commitment therapy for social phobia: outcomes and moderators.

OBJECTIVE: Cognitive behavioral therapy (CBT) is an empirically supported treatment for social phobia. However, not all individuals respond to treatment and many who show improvement do not maintain their gains over the long-term. Thus, alternative treatments are needed. METHOD: The current study (N = 87) was a 3-arm randomized clinical trial comparing CBT, acceptance and commitment therapy (ACT), and a wait-list control group (WL) in participants with a diagnosis of social phobia based on criteria of the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994). Participants completed 12 sessions of CBT or ACT or a 12-week waiting period. All participants completed assessments at baseline and posttreatment, and participants assigned to CBT and ACT also completed assessments 6 and 12 months following baseline. Assessments consisted of self-report measures, a public-speaking task, and clinician ratings. RESULTS: Multilevel modeling was used to examine between-group differences on outcomes measures. Both treatment groups outperformed WL, with no differences observed between CBT and ACT on self-report, independent clinician, or public-speaking outcomes. Lower self-reported psychological flexibility at baseline was associated with greater improvement by the 12-month follow-up in CBT compared with ACT. Self-reported fear of negative evaluation significantly moderated outcomes as well, with trends for both extremes to be associated with superior outcomes from CBT and inferior outcomes from ACT. Across treatment groups, higher perceived control and extraversion were associated with greater improvement, whereas comorbid depression was associated with poorer outcomes. CONCLUSIONS: Implications for clinical practice and future research are discussed.

Aboriginal-mainstream partnerships: exploring the challenges and enhancers of a collaborative service arrangement for Aboriginal clients with substance use issues.

BACKGROUND: Partnerships between different health services are integral to addressing the complex health needs of vulnerable populations. In Australia, partnerships between Aboriginal community controlled and mainstream services can extend health care options and improve the cultural safety of services. However, although government funding supports such collaborations, many factors can cause these arrangements to be tenuous, impacting the quality of health care received. Research was undertaken to explore the challenges and enhancers of a government initiated service partnership between an Aboriginal Community Controlled alcohol and drug service and three mainstream alcohol rehabilitation and support services. METHODS: Sixteen staff including senior managers (n=5), clinical team leaders (n=5) and counsellors (n=6) from the four services were purposively recruited and interviewed. Interviews were semi-structured and explored staff experience of the partnership including the client intake and referral process, shared client care, inter-service communication and ways of working. RESULTS & DISCUSSION: Communication issues, partner unfamiliarity, 'mainstreaming' of Aboriginal funding, divergent views regarding staff competencies, client referral issues, staff turnover and different ways of working emerged as issues, emphasizing the challenges of working with a population with complex issues in a persistent climate of limited resourcing. Factors enhancing the partnership included adding a richness and diversity to treatment possibilities and opportunities to explore different, more culturally appropriate ways of working. CONCLUSION: While the literature strongly advises partnerships be suitably mature before commencing service delivery, the reality of funding cycles may require partnerships become operational before relationships are adequately consolidated. Allowing sufficient time and funding for both the operation and relational aspects of a partnership is critical, with support for partners to regularly meet and workshop arrangements. Documentation that makes clear and embeds working arrangements between partners is important to ameliorate many of the issues that can arise. Given the historical undercurrents, flexible approaches are required to focus on strengths that contribute to progress, even if incremental, rather than on weaknesses which can undermine efforts. This research offers important lessons to assist other services collaborating in post-colonial settings to offer treatment pathways for vulnerable populations.

Australia's contribution to global immunisation.

OBJECTIVE: To review Australian contributions to global immunisation. APPROACH: We summarise Australian scientific and program contributions to vaccines and global immunisation, describe key developments and strengths in Australia's national immunisation program, and outline how both of these can link with Australia's increasing international development budget to build Australia's future contribution to global immunisation. CONCLUSIONS: Australian contributions to vaccines and immunisation have been substantial, and Australia offers a range of good practices in its domestic and development approaches. There are major opportunities to build on this strong track record. These include committing to help roll out important new life-saving vaccines against pneumococcal disease, rotavirus and human papilloma virus (HPV) to the children who need them most, but whose communities can least afford them. IMPLICATIONS: Australia is one of a few countries expanding their aid budgets towards 0.7% development assistance and other development commitments. Given the importance of immunisation to health gains, Australia is well placed to expand its investment in immunisation within its development portfolio. The GAVI Alliance is the best-established global mechanism to do this. Additionally, however, Australia could harness other national and regional mechanisms to support low and middle-income countries, thereby complementing GAVI's focus and global needs.

Longitudinal treatment mediation of traditional cognitive behavioral therapy and acceptance and commitment therapy for anxiety disorders.

OBJECTIVE: To assess the relationship between session-by-session putative mediators and treatment outcomes in traditional cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT) for mixed anxiety disorders. METHOD: Session-by-session changes in anxiety sensitivity and cognitive defusion were assessed in 67 adult outpatients randomized to CBT (n = 35) or ACT (n = 32) for a DSM-IV anxiety disorder. RESULTS: Multilevel mediation analyses revealed significant changes in the proposed mediators during both treatments (p < .001, d = .90-1.93), with ACT showing borderline greater improvements than CBT in cognitive defusion (p = .05, d = .82). Anxiety sensitivity and cognitive defusion both significantly mediated post-treatment worry; cognitive defusion more strongly predicted worry reductions in CBT than in ACT. In addition, cognitive defusion significantly mediated quality of life, behavioral avoidance, and (secondary) depression outcomes across both CBT and ACT (p < .05, R(2) change = .06-.13), whereas anxiety sensitivity did not significantly mediate other outcomes. CONCLUSIONS: Cognitive defusion represents an important source of therapeutic change across both CBT and ACT. The data offered little evidence for substantially distinct treatment-related mediation pathways.

Efficacy of self-administered treatments for pathological academic worry: A randomized controlled trial.

Research on treatments for reducing pathological worry is limited. In particular, academic worry is a common theme in generalized anxiety disorder (GAD) samples as well as non-clinical student samples. Given the high cost of anxiety disorders to society, research is needed to examine the efficacy of self-administered treatments designed to reduce pathological worry. The primary goal of this study was to investigate the benefits of three self-administered interventions for reducing academic worry. College students (N = 113) experiencing clinically significant academic worry were randomized to either: (a) worry exposure (WE); (b) expressive writing (EW); (c) relaxation consisting of pulsed audio-photic stimulation (APS); or (d) waitlist control (WLC). Participants were instructed to practice their interventions three times per week for one month and completed home practice logs online to track treatment adherence. Academic worry, general anxiety, and perceived stress were assessed at baseline and post-treatment. Academic worry and general anxiety were also assessed at a three-month follow-up. Those assigned to the WE and APS conditions showed significant improvement relative to EW and WLC at post-treatment. All treatment conditions showed continued improvement by follow-up, with no between-group differences. Treatment and public health implications are discussed.