Combining diabetes and mental health care: An ethnographic exploration of user involvement in combined care.

PURPOSE: To explore and describe the enactment of user involvement and combined care in a Danish clinic that aimed at providing integrated diabetes and mental health care. DESIGN: An ethnographic study. DATA SOURCES AND METHODS: Data consisted of field notes from 96 hours of participant observations and field notes from 32 informal conversations with healthcare providers, users and relatives as well as 12 semistructured interviews with users. Data were analysed using a thematic analysis. This study reports to the SRQR guidelines. RESULTS: Treatment was not combined as intended if only one healthcare provider handled the consultations. Here, the healthcare providers' focus was often on their own area of expertise-either mental health or diabetes. If more than one healthcare provider handled consultations, the consultations were often divided between them, focussing on one condition at the time. Healthcare providers noted, that learning from peer colleagues was a way to increase the possibility for combined care. Furthermore, combined care was highly dependent on the healthcare providers' ability to involve users' illness experiences in their own care planning. Here, a high level of user involvement increased the levels of combined care during consultations. CONCLUSION: This study set out to explore and describe user involvement and combined care in a specialised diabetes and mental health outpatient clinic. Combined care is complexed and requires that healthcare providers are well-equipped to manage the complexity of delivering care for people with both conditions. The degree of combined care was linked with the healthcare providers' ability to involve users and their knowledge on the condition outside there are of expertise. RELEVANCE TO CLINICAL PRACTICE: A peer-learning environment in combination with clinical guidelines and joint display could support healthcare providers in involving users in own care and when delivering care outside their area of expertise. PUBLIC CONTRIBUTION: No patient or public contribution. Due to the COVID-19 pandemic, the original user council withdraw their consent to participate due to health-related worries and anxiety concerning the pandemic. The user council consisted of three members diagnosed with diabetes and severe mental illness. They were invited to participate in physical meetings, phone or online meetings. Presenting findings from the study to the study participants were also hindered by the second lockdown. This influenced the possibility for data triangulation.

Patient-reported outcome measures in depression.

AIM: Patient-reported outcome measures (PROMs) are increasingly important as a mean for quality assurance. Feasible estimates of recovery can be achieved through the application of Jacobson plots, which is a simple demonstration of the outcome of each case, recommended for clinical use. We applied this approach with PROMs collected regarding group psychotherapy in a mental health service (MHS) setting. We hypothesized a recovery rate of above 50% of all cases, expecting a lower recovery rate amongst patients with severe depression. METHODS: We made a secondary sub-sample analysis of data from patients with unipolar depression (N = 171) within a pragmatic, non-inferiority, randomized controlled clinical trial comparing two cognitive behavior therapy (CBT) group interventions. The treatment consisted of 14 2-hours weekly group CBT sessions. We collected depression PROMs with the Becks Depression Inventory-II and functional levels PROMs with the Work and Social Adjustment Scale at baseline, end-of-treatment, and at a 6-months follow-up. RESULTS: At follow-up, 35% (N = 43/123) of cases with moderate or severe depression (BDI > 19) at baseline reached scores below the cut-off for moderate depression. Recovery rates in severe cases were significantly lower (26.5 vs 52.5%; p = 0.0004). We observed severe functional impairment in 36% of the patients at baseline (52/144) and observed no changes or worsening in scores at a 6-months follow-up in 44% of the patients (64/144). CONCLUSION: We achieved satisfactory remission rates for patients with moderate depression. Patients with severe depression and patients with functional impairment reached recovery rates below the standard of comparable MHSs. Improved MHSs for these patients are needed.

Psychotherapy for patients with schizotypal personality disorder: A scoping review.

BACKGROUND: Treatment of schizotypal personality disorder is complex. Currently, there are no clear evidence-based recommendations for use of psychotherapy for individuals suffering from this mental illness, and studies are sparse. Our aim in this review is to map and describe the existing research and to answer the research question: What do we know about the use of psychotherapy for people with schizotypal personality disorder? METHODS: We conducted a scoping review using systematic searches in the Embase, MEDLINE and PsycINFO databases. Two reviewers screened possible studies and extracted data on subject samples, type of psychotherapy, outcomes and suggested mechanisms of change. The review is based on the PRISMA checklist for scoping reviews. RESULTS: Twenty-three papers were included, and we found a wide variety of study types, psychotherapeutic orientations and outcomes. Few studies emerged that focused solely on schizotypal personality disorder. CONCLUSION: Psychotherapy as a treatment for schizotypal personality disorder is understudied compared with diagnoses such as schizophrenia and borderline personality disorder. Our results included two randomized controlled studies, as well as mainly smaller studies with different approaches to diagnostic criteria, psychotherapeutic orientation and outcome measures. The findings are too sparse and too diverse to make any evidence-based recommendations. We found some indications that psychotherapy may support and assist individuals with schizotypal personality disorder.

Patients' and Therapists' Experiences of Standardized Group Cognitive Behavioral Therapy: Needs for a Personalized Approach.

Personalizing psychotherapy can be challenging within standardized group Cognitive Behavioral Therapy (CBT), in which sessions are structured according to a protocol and must accommodate the needs and preferences of multiple patients. In the current study, we aimed to examine patients' and therapists' experiences of standardized group CBT and identify their perceptions of different patient needs. Furthermore, we explored how these needs can inform possible content of add-on interventions for patients who are not improving as expected during group CBT.We conducted 21 individual in-depth interviews with patients with depression and their therapists about their experiences during group CBT with Routine Outcome Monitoring (ROM) and feedback. Interviews were analyzed by using a hermeneutic-phenomenological thematic analysis. Five themes, representing different patient needs, were identified: (1) Individual attention, (2) Psychological exploration, (3) A focus on the patient's life outside of therapy, (4) Extended assessment, and (5) Agreement on therapeutic tasks.The study supports that "one size does not fit all" when it comes to psychotherapy. Patients have varying needs when they are not making progress in therapy, and these needs, when unmet, can negatively impact the overall experience of group CBT. By acknowledging the unique needs of each patient and providing additional individual sessions as necessary, we can move towards a more personalized approach that maximizes the benefits of group psychotherapy.

Transdiagnostic versus Diagnosis-Specific Group Cognitive Behavioral Therapy for Anxiety Disorders and Depression: A Randomized Controlled Trial.

INTRODUCTION: The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) delivered in a group format could facilitate the implementation of evidence-based psychological treatments. OBJECTIVE: This study compared the efficacy of group UP and diagnosis-specific cognitive behavioral therapy (dCBT) for anxiety and depression in outpatient mental health services. METHODS: In this pragmatic, multi-center, single-blinded, non-inferiority, randomized controlled trial (RCT), we assigned 291 patients with major depressive disorder, social anxiety disorder, panic disorder, or agoraphobia to 14 weekly sessions in mixed-diagnosis UP or single-diagnosis dCBT groups. The primary test was non-inferiority, using a priori criteria, on the World Health Organisation 5 Well-Being Index (WHO-5) at the end of the treatment. Secondary outcomes were functioning and symptoms. We assessed outcomes at baseline, end-of-treatment, and at a 6-month follow-up. A modified per-protocol analysis was performed. RESULTS: At end-of-treatment, WHO-5 mean scores for patients in UP (n = 148) were non-inferior to those of patients in dCBT (n = 143; mean difference -2.94; 95% CI -8.10 to 2.21). Results were inconclusive for the WHO-5 at the 6-month follow-up. Results for secondary outcomes were non-inferior at end-of-treatment and the 6-month follow-up. Client satisfaction and rates of attrition, response, remission, and deterioration were similar across conditions. CONCLUSIONS: This RCT demonstrated non-inferior acute-phase outcomes of group-delivered UP compared with dCBT for major depressive disorder, social anxiety disorder, panic disorder, and agoraphobia in outpatient mental health services. The long-term effects of UP on well-being need further investigation. If study findings are replicated, UP should be considered a viable alternative to dCBT for common anxiety disorders and depression in outpatient mental health services.

Validating the Danish version of the Eating Disorder Quality of Life Scale (EDQLS) in anorexia nervosa.

PURPOSE: The aim of this study was to explore the factor structure of the Danish translation of the eating disorder quality of life scale and evaluate the internal reliability and convergent validity of the scale in a Danish cohort of women with AN. METHODS: The total sample comprised 211 patients diagnosed with anorexia nervosa age 13-40 years. Patients completed questionnaires assessing eating disorder psychopathology, physical and social functioning, and well-being. RESULTS: Factor analyses were not able to support the current division of the scale into 12 factors. We found excellent internal consistency of the eating disorder quality-of-life scale total score. We found relevant associations between quality of life and pre-determined variables. CONCLUSION: This study supports the use of the total score of the eating disorder quality of life scale in assessing quality of life in patients with anorexia nervosa. However, future studies should explore the factor structure of the scale further. LEVEL OF EVIDENCE: III: Evidence obtained from cohort or case-control analytic studies.

E-Library of Authentic Patient Videos Improves Medical Students' Mental Status Examination.

OBJECTIVE: During psychiatric rotation, clerkship students must learn the clinical skill of recording an accurate Mental Status Examination (MSE). The authors built a video e-library consisting of 23 authentic patient videos that were accessible on a secure website during the rotation period, aimed at assisting students' acquisition of MSE skills. METHODS: The authors conducted a prospective case comparison study investigating the impact of the video e-library as "add-on" intervention, on acquisition of MSE skills, as measured by a test consisting of three videos with adjoining forced choice questionnaires. Eighty-five clerkship students had instructions and access to the video e-library whereas 82 did not. A group of clinicians, unfamiliar with the video e-library, was also subjected to the new MSE skills test and they served as a reference group. Outcome was defined as scores of MSE skills measured by the purpose made MSE skills test and entailed evaluation questions on the students' use of the e-library. RESULTS: The MSE skill test score differed between the three groups, and the clinicians scored higher than both student groups (clinicians mean score (M) 12.6; p < 0.001). However, the students with video access scored higher compared to students without access (M 10.7 versus M 9.9, p = 0.04). The e-library was appreciated by the students as helpful (83.6%) and they used it not only for practicing the MSE but also for observation of interviewing techniques. CONCLUSION: The e-library with video vignettes of authentic patients strengthens MSE skills as "add-on" to the psychiatric rotation, and evaluations by the students were positive.

"Caught Between a Rock and a Hard Place"-Between Discourses of Empowerment and Solicitude: Danish Public Sector Service Professionals' Discourses of Nonattendance.

Nonattendance constitutes a profound challenge in public sector services targeting young adults with mental health difficulties. Therefore, researchers and practitioners are occupied with trying to resolve this. For clinicians to be aware of their own naturalized and perhaps inappropriate communicative practices, we investigated the established normative organizational logics behind explanations and strategies related to nonattendance. We performed a critical discourse analysis on material collected through participatory research throughout 2015. Three discourses were identified: solicitude, responsibility, and youth discourse. Although the discourses were complex and entangled, they were used by all practitioners. Furthermore, some of the discourses, especially the responsibility and the solicitude discourses, were inherently tension filled, and practitioners experienced frustration in dealing with these tensions. The youth discourse can be understood as a coping mechanism to deal with these tensions because it distributes responsibility for nonattendance to general social and cultural processes.

Prevalence of delirium among patients at a cancer ward: Clinical risk factors and prediction by bedside cognitive tests.

Background Delirium is a frequent psychiatric complication to cancer, but rarely recognized by oncologists. Aims 1. To estimate the prevalence of delirium among inpatients admitted at an oncological cancer ward 2. To investigate whether simple clinical factors predict delirium 3. To examine the value of cognitive testing in the assessment of delirium. Methods On five different days, we interviewed and assessed patients admitted to a Danish cancer ward. The World Health Organization International Classification of Diseases Version 10, WHO ICD-10 Diagnostic System and the Confusion Assessment Method (CAM) were used for diagnostic categorization. Clinical information was gathered from medical records and all patients were tested with Mini Cognitive Test, The Clock Drawing Test, and the Digit Span Test. Results 81 cancer patients were assessed and 33% were diagnosed with delirium. All delirious participants were CAM positive. Poor performance on the cognitive tests was associated with delirium. Medical records describing CNS metastases, benzodiazepine or morphine treatment were associated with delirium. Conclusions Delirium is prevalent among cancer inpatients. The Mini Cognitive Test, The Clock Drawing Test, and the Digit Span Test can be used as screening tools for delirium among inpatients with cancer, but even in synergy, they lack specificity. Combining cognitive testing and attention to nurses' records might improve detection, yet further studies are needed to create a more detailed patient profile for the detection of delirium.

Schizophrenia and type 2 diabetes: Perceptions and understandings of illness management in everyday life.

People with schizophrenia and type 2 diabetes face complex challenges in daily life and the management of both illnesses is burdensome. This qualitative interview study aimed to explore perceptions and understandings of the day-to-day management of schizophrenia and type 2 diabetes. Fourteen semi-structured interviews were conducted between January 2020 and October 2021 in the participants' respective mental health clinics, in their homes or by phone. Thematic analysis led to four themes representing participants' self-management strategies and perceived challenges. The first theme showed that participants use self-learned strategies for managing schizophrenia. In contrast, they perceived type 2 diabetes self-management as governed by a set of rules and guidelines given by health professionals. The second theme showed that both psychotic and negative symptoms present challenges to diabetes management. Theme 3 illustrated that participants consider their type 2 diabetes to be a very serious illness. They worried about potential long-term consequences and expressed wishes and motivation to improve their lifestyle. The final theme showed that participants discuss challenges related to their schizophrenia with family and friends but not type 2 diabetes. In conclusion, this study highlights the importance of considering individual challenges and everyday routines when supporting this population. It underlines the need for future research to further explore the complexity of managing the illnesses and to understand the needs for treatment and support.

[Transdiagnostic cognitive behaviour therapy for anxiety disorders].

Evidence-based diagnosis specific cognitive behaviour therapy (CBT) protocols for anxiety disorders, currently recommended in national clinical guidelines, have shortcomings in relation to the application of group therapy in the mental health service. Transdiagnostic CBT is theory-driven, targeting common personality traits and emotion-driven behaviour observed in all of the anxiety disorders. This review recapitulates the theory and the evidence base. More head-to-head comparison studies are needed, in particular concerning group therapy. The current evidence is, however, very promising.

User accounts on received diabetes and mental health care in a Danish setting - An interview study.

People with coexisting type 1 and 2 diabetes and mental illness have a higher mortality rate compared to the general population, among other reasons due to unregulated diabetes. One explanation might be the complexity of managing both conditions. In this interview study, we explored the accounts of delivered diabetes and mental health care of 16 individuals living with coexisting diabetes and mental illness in Denmark. A thematic analysis by Braun and Clarke was applied in the analysis. Some of the participants described the care for diabetes and mental illness to be inextricably linked to each other. Therefore, health care providers ought to focus and knowledge of both conditions as essential components in the care provided. The participants accounted for support needs in other settings beyond diabetes and mental health outpatient clinics, such as the family doctor, residential institutions, and community care. However, the inefficient collaboration between these health care settings is one of the barriers to supporting the participants' self-management.

Attenuation of beta and gamma oscillations in schizophrenia spectrum patients following hand posture perturbation.

Several electroencephalographic (EEG) studies in schizophrenia report that the patients have reduced evoked gamma activity following visual and auditory stimulation. Somatosensory gamma activity has not previously been examined. It has been suggested that a dysfunction basic to schizophrenia spectrum traits would involve proprioceptive information processing and this has recently been supported by the finding of diminished latency of early proprioceptive evoked potentials in a sample of chronic schizophrenia patients. The proprioceptive stimulus used previously, and presently, consisted of an abrupt increase of weight on a hand-held load. Eighteen first-time admitted schizophrenia spectrum patients and 18 healthy matched comparison subjects were included. Proprioceptive evoked potentials were recorded as 64-channels EEG for 120 trials in two runs differing in sequence. Contra-lateral evoked beta (latency 90 ms, frequency 21 Hz) and gamma (latency 70 ms, frequency 32 Hz) oscillations were attenuated in the patient group. The healthy comparison subjects had increased gamma amplitude in the left hemisphere in the regular sequence, a phenomenon not seen in the patients. The deviant findings were unexpectedly more circumscribed in the schizophrenia than in the schizotypal personality disorder (SPD) patients. Future studies should include several concurrent psychophysiological measures.

A Danish translation of the eating disorder quality of life scale (EDQLS).

BACKGROUND: In Denmark, only generic health-related quality of life measures have been developed to assess quality of life in patients with eating disorders. So far, no disease-specific questionnaires have been translated and validated. The objective of this study was to translate the Eating Disorders Quality of Life Scale into Danish and to perform a preliminary validation of the questionnaire in a small sample. METHODS: The translation process was conducted according to recommendations from the World Health Organization, using the WHO-5 Well-Being Index as a reference standard. The validation process included 41 outpatients with eating disorders. Patients were recruited from specialized outpatient clinics in the Capital Region of Denmark and asked to complete the quality of life questionnaire and the WHO-5 Well-Being Index. RESULTS: This study found poor agreement, but high correlation, between the two self-rating scales. CONCLUSION: The translated questionnaire was concluded to be valid. However, a replication study on a larger sample with more male patients and more extensive symptoms is necessary.

Shift-invariant multilinear decomposition of neuroimaging data.

We present an algorithm for multilinear decomposition that allows for arbitrary shifts along one modality. The method is applied to neural activity arranged in the three modalities space, time, and trial. Thus, the algorithm models neural activity as a linear superposition of components with a fixed time course that may vary across either trials or space in its overall intensity and latency. Its utility is demonstrated on simulated data as well as actual EEG, and fMRI data. We show how shift-invariant multilinear decompositions of multiway data can successfully cope with variable latencies in data derived from neural activity--a problem that has caused degenerate solutions especially in modeling neuroimaging data with instantaneous multilinear decompositions. Our algorithm is available for download at www.erpwavelab.org.

Approaching patients with hyperreflectivity and perplexity: an empirical qualitative investigation.

OBJECTIVE: Perplexity and hyperreflectivity are considered important aspects of self-disorders in patients with schizophrenia, yet knowledge of the appropriate psychotherapy for these patients is sparse. We aimed to explore how phenomenological psychologists or psychiatrists described their approach to these patients and their own emotional response when hyperreflectivity and perplexity emerged in therapy or consultations. METHODS: Four e-mail interviews with experienced clinical researchers within the field of phenomenology and schizophrenia were examined using a double hermeneutic qualitative analysis. RESULTS: The informants offered reassurance by authority and the encouragement of sharing of experiences interlaced in the beginning of therapy. Later they went on relating expressions of hyperreflectivity and perplexity to emotions, life events and goals. They described feelings of admiration and professional recognition along with worry, insecurity and sadness. CONCLUSION: The list of primary themes covers what might seem very basic therapeutic interventions. However, the careful and open-minded manner in which these were carried out was noteworthy. The double task of staying closely attuned to the patient's airy reflections and, at the same time, when the patient was ready for it, carefully making links to domains of the patient's everyday life, was clearly molded to patients with fragile attachment.

Behavioral response to novelty correlates with dopamine receptor availability in striatum of Göttingen minipigs.

Behavioral response to novelty in rats has been linked both to dopamine transmission in the ventral striatum, and to propensity to self-administer psychostimulant drugs. In order to probe the relationship between behavioral response to novelty and dopamine systems we have developed a behavioral model for correlation with positron emission tomography (PET) of dopamine transmission in brain of Göttingen minipigs. In the present study, we measured exploration of a novel object by recording the number of contacts, and duration of contact with a novel object, in groups of six male and six female adult minipigs. We hypothesized that these novelty scores would correlate with the amphetamine-evoked dopamine release in ventral striatum, measured 2 weeks later in a PET study of the availability of binding sites for the dopamine D2/3 antagonist [11C]raclopride. There were significant correlations between duration of contact with a novel object and the amphetamine-evoked reductions in binding potential (DeltapB) in the left ventral striatum of the 12 animals; Comparison of results by gender revealed that the correlation was driven mainly by the male group, and was not present in the female group. We interpret these results to show that propensity to explore an unfamiliar object is relatively elevated in pigs with low basal occupancy of dopamine D2/3 receptors by endogenous dopamine, and with high amphetamine-induced occupancy of released dopamine in the male pigs.

Mapping the amphetamine-evoked dopamine release in the brain of the Göttingen minipig.

The availability of dopamine D(2/3) binding sites in brain of six male and six female Göttingen minipigs was measured in a baseline condition and after challenge with amphetamine sulfate (1mg/kg, i.v.) in PET studies with [(11)C]raclopride. Maps of the binding potential (pB; B(max)/K(d)) of [(11)C]raclopride were spatially normalized and co-registered to a common stereotaxic coordinate system for pig brain. The pB maps were then analyzed by volume of interest and voxel-wise comparisons of gender and condition. The mean baseline pB tended to be 10-20% higher in striatum of the female group, but this gender difference was not significant. Variance of the mean baseline pB was higher in the males (44%) than in females (30%), but there was no correlation between pB and individual plasma cortisol or testosterone concentrations. Using statistical parametric mapping, we detected a focus in the right posterior putamen where the magnitude of the amphetamine-evoked decrease in pB was greater in the male than in the female group. Thus, the spatial pattern of reactivity of dopamine D(2/3) receptor availability to amphetamine challenge is not identical in male and female pigs. Within the entire population, the decline in pB evoked by amphetamine (Delta pB) was greater in the ventral striatum (-28%) than in the caudate nucleus (-17%), consistent with earlier reports in monkeys and humans. The magnitude of Delta pB correlated highly with the baseline pB values in all divisions of the striatum. Based upon the principles of competitive binding, the slope of this empirical relationship, f(i), is equal to the fraction of [(11)C]raclopride binding sites sensitive to endogenous dopamine; the magnitude of this fraction ranged from 0.29 in the caudate to 0.36 in the ventral striatum.

[Anorexia nervosa is frequently associated with psychiatric co-morbidity]. / Anorexia nervosa ses ofte sammen medandre psykiatriske lidelser.

Recent literature is explored focusing on the relationship between symptoms of anorexia nervosa (AN) and other psychiatric disorders and lines of treatment. In AN, restrictive subtype, anxiety and obsessive-compulsive disorders are the most frequent co-morbidities. In AN, bulimic subtype, depression, emotional instability/borderline and dependency disorders are most frequent. Psychopharmacological treatment could be tried in cases with AN and co-morbid depression, but otherwise the evidence base is lacking and pharmacological treatment relies on case stories and experience.