A randomised controlled trial of psychotherapy and cognitive remediation to target cognition in mood disorders.

OBJECTIVE: To examine the impact of a treatment package combining Interpersonal and Social Rhythm Therapy (IPSRT) and cognitive remediation (CR), vs IPSRT alone, on cognition, functioning, and mood disturbance outcomes in mood disorders. METHODS: A pragmatic randomised controlled trial in adults with bipolar disorder (BD) or major depressive disorder (MDD), recently discharged from mental health services in Christchurch, New Zealand, with subjective cognitive difficulties. Individuals were randomised to a 12-month course of IPSRT with CR (IPSRT-CR), or without CR (IPSRT). In IPSRT-CR, CR was incorporated into therapy sessions from approximately session 5 and continued for 12 sessions. The primary outcome was change in Global Cognition (baseline to 12 months). RESULTS: Sixty-eight individuals (BD n = 26, MDD n = 42; full/partial remission n = 39) were randomised to receive IPSRT-CR or IPSRT (both n = 34). Across treatment arms, individuals received an average of 23 IPSRT sessions. Change in Global Cognition did not differ between arms from baseline to treatment-end (12 months). Psychosocial functioning and longitudinal depression symptoms improved significantly more in the IPSRT compared with IPSRT-CR arm over 12 months, and all measures of functioning and mood symptoms showed moderate effect size differences favouring IPSRT (0.41-0.60). At 18 months, small to moderate, non-significant benefits (0.26-0.47) of IPSRT vs IPSRT-CR were found on functioning and mood outcomes. CONCLUSIONS: Combining two psychological therapies to target symptomatic and cognitive/functional recovery may reduce the effect of IPSRT, which has implications for treatment planning in clinical practice and for CR trials in mood disorders.

Patients' Perceptions of Functional Improvement in Psychotherapy for Mood Disorders.

OBJECTIVE: This study aimed to examine participants' experiences of interpersonal and social rhythm therapy, with or without cognitive remediation, and the impact of this intervention on their functioning. METHODS: This qualitative study drew data from follow-up interviews of 20 participants who completed the 12-month intervention as part of a randomized controlled trial. The qualitative data were collected through semistructured interviews and were analyzed with thematic analysis. RESULTS: The 20 participants (11 men, 9 women, ages 22-55, median age=32) reported that interpersonal and social rhythm therapy (content and process) as an adjunct to medication, alone or in combination with cognitive remediation, was effective in improving their functioning. They described these improvements as facilitated by a new sense of control and confidence, ability to focus, new communication and problem-solving skills, and better daily routines. CONCLUSIONS: Participants with recurrent mood disorders described improved functioning related to therapies that formulate their mood disorder in terms of a model, such as interpersonal and social rhythm therapy with or without cognitive remediation, that provides an understandable and evidence-based rationale, facilitates a sense of control and confidence by supporting the person in undertaking practical routines that can be integrated into daily life, focuses on communication and problem-solving skills, and engenders a sense of hope by working with the person to develop self-management strategies relevant to their specific symptom experiences and the life they choose to live.

Interpersonal and Social Rhythm Therapy for Patients With Major Depressive Disorder.

OBJECTIVE: This study aimed to conduct a safety analysis among patients with major depressive disorder receiving interpersonal and social rhythm therapy (IPSRT) with and without cognitive remediation. METHODS: This preliminary safety analysis of the outcomes of patients with major depressive disorder was part of a larger randomized controlled trial (RCT) in which patients with bipolar disorder and major depressive disorder received IPSRT; half were randomly assigned to receive additional cognitive remediation. The study focused on patients with major depressive disorder because IPSRT had not been trialed with this group; their outcomes were compared with those of patients with bipolar disorder. Data from the first 30 RCT participants were used to examine whether the intervention had adverse effects, whether mood symptoms and functioning improved over 12 months, and whether there was a signal of benefit. Mood symptoms were measured at baseline and 12 months with the Longitudinal Interval Follow-Up Evaluation and the Quick Inventory of Depressive Symptoms-Self-Reported; functioning was measured with the Social Adjustment Scale. RESULTS: A total of 63% (N=19) of participants were diagnosed with bipolar disorder and 27% (N=11) with major depressive disorder. No adverse effects were found for those with major depressive disorder, and improvements were seen in mean depressive and functioning scores at 12 months compared with baseline, with moderate to large effect sizes. CONCLUSIONS: IPSRT may be a clinically effective intervention for patients with major depressive disorder. Outcomes related to cognitive functioning and the effects of cognitive remediation will be reported at the end of the trial.

Distracted Pedestrian Behavior on two Urban College Campuses.

Pedestrian injuries injure about 180,000 individuals and kill 6000 each year in the United States, and pedestrian injury rates have increased each of the last several years. Distracted pedestrian behavior may play a role in the trend of increasing risk for pedestrian injury. Using in vivo behavioral coding over the course of  two weeks on two urban college campuses, this study aimed to (1) understand the type and rate of distractions engaged in by pedestrians on urban college campuses, and (2) investigate the impact of distraction on street-crossing safety and behavior. A total of 10,543 pedestrians were observed, 90% of them young adults. Over one-third of those pedestrians were distracted while actively crossing roadways. Headphones were the most common distraction (19% of all pedestrians), followed by text-messaging (8%) and talking on the phone (5%). Women were more likely to text and talk on the phone than men, and men were more likely to be wearing headphones. Distracted pedestrians were somewhat less likely to look for traffic when they entered roadways. As handheld device usage continues to increase, behavioral interventions should be developed and implemented. Changes to policy concerning distracted pedestrian behavior, including improvement of the built environment to reduce pedestrian risk, should be considered in busy pedestrian areas like urban college campuses.

Systematic Review: Interventions to Educate Children About Dog Safety and Prevent Pediatric Dog-Bite Injuries: A Meta-Analytic Review.

Objective: Dog-bite injury posits a significant threat to children globally. This review evaluated efficacy of cognitive/behavioral interventions for improving children's knowledge and behaviors around dogs. Methods: Manuscripts published before January 3, 2014 evaluating cognitive/behavioral interventions for dog-bite prevention among children <18 years of age were eligible for inclusion. Among 2,270 abstracts screened, 123 full texts were retrieved. Twelve studies were included in the qualitative synthesis; nine were included in the meta-analysis. Risk of bias and quality of evidence were evaluated. Results: Cognitive/behavioral interventions had a moderate effect in improving children's knowledge and a larger effect in improving children's behavior with dogs. The most effective intervention strategies were video for knowledge and instruction with live dogs for behaviors. Quality of evidence was poor. Conclusions: Cognitive/behavioral interventions have potential to improve both children's knowledge and behaviors around dogs. Future interventions should include multiple follow-ups on dog-bite rates from an international perspective using rigorous randomized controlled trials.

Children's recognition of dangerous household products: child development and poisoning risk.

OBJECTIVE: Preliterate children may be poisoned because they fail to distinguish safe versus hazardous household products. METHODS: Study 1: A total of 228 children aged 18-54 months completed four tasks assessing ability to recognize product safety. Study 2: A total of 68 children aged 17-31 months chose products to drink from pairs of dangerous versus beverage bottles. Study 3: A total of 119 children aged 18-42 months sorted 12 objects into toys, things you can drink, and things that are bad/dangerous. RESULTS: Left alone, children frequently touched dangerous household products. Children frequently misidentified poisonous products as safe. Some developmental trends emerged. The following packaging features apparently helped children recognize danger: black bottle color; opaque packaging; salient symbols like insects; lack of pointy spouts; squared, not round, bottles; and metal, not plastic, containers. CONCLUSIONS: Developing cognition helps preliterate children distinguish safe from dangerous household products. Multiple aspects of product packaging may reduce child poisoning risk if implemented by industry or policy.

Non-pharmacological strategies for treatment of inpatient depression.

OBJECTIVE: To examine the evidence for non-pharmacological interventions in the treatment of moderate to severe depression in an inpatient setting. METHOD: An integrative review of original research papers was conducted. The electronic databases CINAHL, MEDLINE and PsychINFO were searched using the following search terms: depression, psychosocial, psychosocial intervention, therapy, and inpatient. RESULTS: Twelve studies were identified in the search for non-psychopharmacological interventions for depression commenced in an inpatient setting. The interventions included psychotherapies, behavioural activation, and chronotherapeutic interventions (controlled exposure to environmental stimuli). These studies suggest it is possible to engage severely depressed inpatients in structured interventions in an inpatient environment. The majority of studies reported favourable outcomes for the interventions compared to a control, but methodological issues were common. CONCLUSIONS: A diverse range of treatment strategies has been identified in this review. These studies provide evidence that non-pharmacological treatments for depression can be given to enhance outcomes and that research can be undertaken in inpatient settings. Whilst the evidence base has limitations, this review also highlights therapeutic and research opportunities in this area.

Systematic review and meta-analysis of behavioral interventions to improve child pedestrian safety.

OBJECTIVE: Pedestrian injuries represent a pediatric public health challenge. This systematic review/meta-analysis evaluated behavioral interventions to teach children pedestrian safety. METHODS: Multiple strategies derived eligible manuscripts (published before April 1, 2013, randomized design, evaluated behavioral child pedestrian safety interventions). Screening 1,951 abstracts yielded 125 full-text retrievals. 25 were retained for data extraction, and 6 were later omitted due to insufficient data. In all, 19 articles reporting 25 studies were included. Risk of bias and quality of evidence were assessed. RESULTS: Behavioral interventions generally improve children's pedestrian safety, both immediately after training and at follow-up several months later. Quality of the evidence was low to moderate. Available evidence suggested interventions targeting dash-out prevention, crossing at parked cars, and selecting safe routes across intersections were effective. Individualized/small-group training for children was the most effective training strategy based on available evidence. CONCLUSIONS: Behaviorally based interventions improve children's pedestrian safety. Efforts should continue to develop creative, cost-efficient, and effective interventions.

Parental coping and posttraumatic stress symptoms among pediatric cancer populations: tests of competing models.

OBJECTIVE: The objective of this study is to examine the relation between parental coping style and the risk of parental and child posttraumatic stress symptoms (PTSS) among pediatric cancer survivors. METHODS: Child survivors of cancer ranging from 6 to 16 years of age (N = 111) completed standardized measures of depression and PTSS, while their parents completed standardized measures of PTSS and coping styles. RESULTS: Correlational analyses revealed that active and passive coping strategies were positively related to parental PTSS. Although child and parental PTSS were significantly related to each other, only one parental coping strategy-using substances-was significantly related to child PTSS. Regression analyses revealed support for a mediation and not for a moderation model for this relation, thereby suggesting that the relation between parental and child PTSS is mediated by parental substance use. CONCLUSIONS: Clinical implications including identifying risk factors for PTSS among pediatric cancer survivors are discussed.

Why people choose to participate in psychotherapy for depression: A qualitative study.

WHAT IS KNOWN ON THE SUBJECT?: Medication does not always resolve a serious mood episode, and there is evidence that it needs to be combined with an evidence-based psychotherapy to promote symptomatic and functional recovery. There is little known about what people with serious mood disorders want from mental health services to manage their mood. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Participants in this study wanted a framework other than the medical model for understanding and managing their mood. Their motivation to commence psychotherapy was based on a sense of having hit rock bottom and a need for understanding what was happening in order to better manage their mood. ABSTRACT: Introduction There is little known about the motivations for people to participate in psychotherapy for depression. Aim To explore why people, with a diagnosis of major depressive episode, chose to take part in a psychotherapy study and what they expected it to involve. Method This was a qualitative study of participants' motivations and understandings of psychotherapy for depression. Data were collected using semi-structured interviews and analysed using thematic analysis. Findings Eight females and eight males with an age range from 21 years to 55 years were recruited. Three themes were identified that described why participants chose to participate in psychotherapy: medication was not enough, a turning point and making sense of experience. The participants chose to participate in psychotherapy after finding that medication was insufficient and this combined with a sense of crisis motivated them to engage in psychotherapy in order to learn to manage their mood differently. Discussion The participants recognized that they wanted a framework other than a medical model with its reliance on medication, in order to make sense of their experiences and develop new self-management strategies. Implications for Practice Our study suggests that some people experiencing a serious mood disorder access psychotherapy after "hitting rock bottom" and finding insufficient help from medications. Mental health nurses need to be aware people do not always want a medical model approach to treatment of serious mood disorders and they need to provide the opportunity of engaging in a psychotherapeutic framework in order to better understand and manage their mood.

Patients' experiences of cognitive functioning in recurrent depression: A qualitative study.

WHAT IS KNOWN ON THE SUBJECT?: Recurrent depressive episodes involve significant morbidity, suicide risk and recurrent hospitalizations. In both major depressive disorder and bipolar disorder, there are significant impairments in functioning following resolution of acute symptoms. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This paper provides an in-depth qualitative understanding of the subjective experience of cognitive impairment following a depressive episode in a recurrent mood disorder. It identifies descriptions of two types of experience (being stuck and being preoccupied with one's thoughts) that led to impairments in concentration, memory, organization and decision-making. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Mental health nurses need to develop an awareness of the impact of cognitive difficulties in the process of recovery from recurrent mood disorders. Mental health nurses need to provide knowledgeable reassurance, information and interventions to people who experience cognitive difficulties to provide a framework of understanding that promotes recovery. ABSTRACT: Introduction People who experience recurrent depressive episodes often have ongoing cognitive problems that impact on their functional recovery. These cognitive difficulties have been identified as impacting on social, interpersonal and occupational functioning and can result in vulnerability to relapse. Aim The aim of this qualitative study was to explore participants' subjective experiences of cognitive impairment after discharge from mental health services following treatment for recurrent depression. Methods The study was designed as a qualitative study in order to best capture participants' subjective experiences. Data were collected by semi-structured interviews and were analysed using a process of thematic analysis. Results Twenty participants took part in this study. All participants described experiences of either 1) "being stuck"; or 2) "being preoccupied with own thoughts"; however, all participants described the experiences in the third theme: "it stops you living to your potential." Implications for practice In order to promote recovery in a meaningful way, mental health nurses need to provide information about and strategies for managing cognitive difficulties associated with recurrent mood disorders.

Drug interaction in a renal transplant patient: cyclosporin-Neoral and orlistat.

An overweight 56-year-old type II diabetic on peritoneal dialysis (body mass index 35 kg/m(2)) was taking Orlistat for some months up until live-unrelated renal transplantation. Despite oral cyclosporin A (CyA) for 48 hours pretransplantation, it was very difficult to achieve adequate CyA blood levels for the first week postengraftment despite the use of much larger oral CyA doses. After opening his bowels on day 7, and the use of 3 days intravenous CyA, good CyA blood levels were achieved then maintained with conventional oral doses. The authors believe that this case shows important interactions between CyA and Orlistat.