Barriers and facilitators to the implementation of a stepped care intervention for personality disorder in mental health services.

BACKGROUND: Individuals with personality disorders-particularly borderline personality disorder-are high users of mental health treatment services. Emergency service responses often focus on crisis management, and there are limited opportunities to provide appropriate longer term evidence-based treatment. Many individuals with personality disorders find themselves in a revolving cycle between emergency departments and waiting for community treatment. A stepped care approach may help to triage clients and allow access to interventions with minimal client, clinician and system burden. This study aims to understand the facilitators and barriers to real-world implementation of a stepped care approach to treating personality disorders. METHODS: Managers and clinicians of health services engaged in implementation were interviewed to obtain accounts of experiences. Interviews were transcribed and thematically analysed to generate themes describing barriers and facilitators. RESULTS: Participants identified personal attitudes, knowledge and skills as important for successful implementation. Existing positive attitudes and beliefs about treating people with a personality disorder contributed to the emergence of clinical champions. Training facilitated positive attitudes by justifying the psychological approach. Management support was found to bi-directionally effect implementation. CONCLUSIONS: This study suggests specific organizational and individual factors may increase timely and efficient implementation of interventions for people with personality disorders. © 2019 John Wiley & Sons, Ltd.

A double-blind, sham-controlled trial of transcranial direct current stimulation for the treatment of depression.

Two recent sham-controlled studies found that transcranial direct current stimulation (tDCS) was an effective treatment for depression. As tDCS is painless, relatively safe and inexpensive, its efficacy in treating depression warrants further investigation. This double-blind, randomized study tested tDCS at the same stimulation parameters as a previous positive study (1 mA current strength, five treatment sessions, active or sham, given on alternate days) in 40 depressed participants. Anodal stimulation was centred over the left dorsolateral prefrontal cortex, with the cathode placed on the lateral aspect of the contralateral orbit. tDCS was continued up to a total of ten active sessions per participant. Mood outcomes were measured by psychiatrist raters blind to treatment condition using the Montgomery-Asberg and other depression rating scales. Psychomotor speed was assessed immediately before and after a single tDCS session and attention, frontal executive function, working memory and verbal learning were assessed after each group of five sessions. Overall depression scores improved significantly over ten tDCS treatments, but there was no between-group difference in the five-session, sham-controlled phase. tDCS was found to be safe, with no adverse effects on neuropsychological function, and only minor side-effects. It is recommended that the efficacy of tDCS in depression be further evaluated over a longer treatment period, using enhanced stimulation parameters.

Transcranial direct current stimulation priming of therapeutic repetitive transcranial magnetic stimulation: a pilot study.

OBJECTIVES: Repetitive transcranial magnetic stimulation (rTMS) has been shown to be a safe treatment of depression, and research efforts are now largely focused on strategies to enhance its efficacy. Motor cortex experiments suggest that the effects of rTMS can be enhanced by first priming the same cortical area with transcranial direct current stimulation (tDCS). We explored this approach in depressed subjects. MATERIALS AND METHODS: Seven depressed subjects were given sessions of combined tDCS-rTMS to the left dorsolateral prefrontal cortex, exploring a range of tDCS and rTMS stimulation parameters and interstimulation intervals. Effects of repeated stimulation sessions on mood state and neuropsychological functioning were evaluated. RESULTS: Most of the subjects showed little improvement with cathodal tDCS followed by 10-Hz rTMS, although 2 subjects showed marked improvement, one after a single stimulation session. Anodal tDCS followed by rTMS did not lead to any improvement. Preconditioning with tDCS seemed to greatly exacerbate the pain of subsequent rTMS. No adverse effects on neuropsychological functioning were observed. CONCLUSIONS: Overall, preconditioning with cathodal tDCS followed by rTMS did not result in greater antidepressant efficacy than rTMS given at similar parameters in open trials, although the dramatic response in 1 subject is encouraging. Outcomes may be highly dependent on the exact stimulation paradigm in which tDCS and rTMS are combined. Researchers should be aware that preconditioning with tDCS may greatly increase the pain experienced with subsequent rTMS.

Repetitive transcranial magnetic stimulation as treatment for anxiety disorders.

Repetitive transcranial magnetic stimulation (rTMS) is a noninvasive and generally well-tolerated method of focally stimulating brain regions. It has been shown to be efficacious in the treatment for depression, but only to a limited degree. It has also been investigated for the treatment of some anxiety disorders, particularly obsessive-compulsive disorder, post-traumatic stress disorder and panic disorder. While anecdotal reports and open studies have suggested a therapeutic role for rTMS in anxiety disorders, controlled studies, which have varied greatly in terms of rTMS administration, have not shown it to be superior to placebo. Furthermore, reports in animal models of anxiety have not been consistent. Therefore, to date, there is no convincing evidence for the clinical role of rTMS in anxiety disorders. Further research is needed, drawing on advances in our understanding of pathological neurocircuitry in anxiety disorders and the mechanisms of action by which rTMS may alter that neurocircuitry. With advances in neuroimaging technology, this understanding is likely to be more accessible than it has been in the past.

Pharmacological attenuation of electroconvulsive therapy--induced cognitive deficits: theoretical background and clinical findings.

Electroconvulsive therapy (ECT) is an effective treatment for depression and other psychiatric disorders. However, the practice of ECT is limited by memory and nonmemory cognitive adverse effects. Technical strategies such as a preference for unilateralover bilateral ECT and low-dose over high-dose stimulation reduce these cognitive adverse effects but may also be associated with lesser treatment efficacy or slower treatment response. This article therefore reviews the use of psychopharmacological agents in the attenuation of ECT-induced cognitive deficits with 2 objectives: the identification of implicated mechanisms and the identification of putative efficacy in both animal and human studies. Drugs examined include N-methyl-d-aspartate receptor antagonists, cyclooxygenase inhibitors, calcium channel blockers, cholinesterase inhibitors, glucocorticoid receptor antagonists, thyroid hormones, opioid antagonists, NO donors, nootropic agents, and other medications. Although the clinical data at present are sparse and inconsistent, many recently opened lines of research improve our understanding of the mechanisms involved as well as suggest possible avenues for the testing of new treatments with the potential to attenuate the cognitive adverse effects of ECT.

A report on mood and cognitive outcomes with right unilateral ultrabrief pulsewidth (0.3 ms) ECT and retrospective comparison with standard pulsewidth right unilateral ECT.

BACKGROUND: Electroconvulsive therapy (ECT) is a highly effective treatment for depression but its use is limited by the risk of cognitive side effects. This study explored the potential of a novel approach, ultrabrief pulsewidth (0.3 ms) right unilateral (RUL-UB) ECT, to minimise cognitive effects while preserving efficacy. METHODS: Mood and neuropsychological functioning were objectively rated in 30 patients over a course of RUL-UB ECT at 6 times seizure threshold. Results (mood outcomes, ECT treatment parameters) were compared with a retrospectively assessed group of 30 age and gender matched patients who received RUL ECT (1.0 ms pulsewidth, 3.5 times seizure threshold) at the same hospital. RESULTS: Six treatments of RUL-UB ECT resulted in relatively few cognitive side effects, compared to reports of previous studies. The number of responders did not differ between groups but significantly more treatments were required in the RUL-UB group, suggesting a slower speed of response. LIMITATIONS: Patients were not randomised to the two forms of ECT and data was obtained retrospectively in the RUL ECT comparison group. CONCLUSIONS: This study suggests that RUL-UB ECT can be effective in treating depression while incurring lesser cognitive side effects than a commonly used form of RUL ECT, but a greater number of treatments may be required for response.