Who are you after psychedelics? A systematic review and a meta-analysis of the magnitude of long-term effects of serotonergic psychedelics on cognition/creativity, emotional processing and personality.

This systematic review and a meta-analysis synthesised the results from contemporary, randomized and non-randomized controlled studies to assess lasting (one week minimum) changes on cognition/creativity, emotional processing and personality from serotonergic psychedelics. PubMed, Embase and PsycInfo were searched in July 2022. Risk of bias was assessed using Rob 2.0 and ROBINS-I. Ten studies met the eligibility criteria which involved 304 participants. No statistically significant effects were found for the majority outcome measures across the three constructs. A meta-analysis of emotional recognition outcomes found an overall significant effect for faster reaction times in the active treatment groups for disgust (SMD=-0.63, 95% CI=[-1.01 to -0.25], I2 = 65%) and sadness (SMD=-0.45, 95% CI=[-0.85 to -0.06], I2 = 60%). Future research should include larger samples, better control conditions, standardized doses and longer follow-up periods to confirm these preliminary findings.

Mindfulness-enhanced internet-based cognitive behavioural therapy for anxiety and depression: Outcomes in routine care.

BACKGROUND: Clinical trials support the efficacy of mindfulness-enhanced, internet-based cognitive behavioural therapies (CBT) in reducing anxiety and depression symptom severity. However, it is unclear how effective these interventions are when delivered in routine clinical care settings. This study investigated the utilisation and treatment outcomes of an online mindfulness-enhanced CBT program in the general Australian community. METHODS: Over a one-year study period, 2187 adults commenced the online mindfulness-enhanced CBT program. The program consisted of six sequential lessons to be completed within 90 days. Participants (mean age= 39 ± 14 years, 68 % female) completed measures of symptom severity for anxiety, depression, and psychological distress at pre-, mid- and post-treatment. Treatment effects were assessed via intention-to-treat linear mixed models with Hedges' g effect size calculations. RESULTS: From pre- to post-treatment, the mindfulness-enhanced CBT program was associated with medium and large effect sized reductions in generalised anxiety symptom severity (g = 0.80, 95%CI: 0.74-0.86), depression symptom severity (g = 0.74, 95%CI: 0.68-0.80), and psychological distress (g = 0.97, 95%CI: 0.90-1.03). Program adherence was modest with approximately 30 % of participants completing all six lessons of the program. LIMITATIONS: This study is limited by its lack of a comparator condition, longer-term follow-up, and assessment of the reasons for participant non-adherence. The relative acceptability and effectiveness of mindfulness versus CBT components was not examined. CONCLUSION: This study supports the effectiveness of mindfulness-enhanced iCBT for symptoms of anxiety and depression when delivered in a routine care setting under the supervision of community health care practitioners.

Online cognitive behaviour therapy for maternal antenatal and postnatal anxiety and depression in routine care.

BACKGROUND: Perinatal depression and anxiety are associated with significant adverse effects for the mother and child. Online cognitive behavioural therapy (iCBT) can provide scalable access to psychological interventions to improve perinatal depression and anxiety, however, few studies have examined the effectiveness of these interventions in routine care. This study investigated the uptake and treatment outcomes of women living in the Australian community who enrolled in a pregnancy or postnatal iCBT program for their symptoms of depression and anxiety. METHODS: 1502 women commenced iCBT (529 pregnancy and 973 postnatal) and completed measures of anxiety and depression symptom severity, and psychological distress pre- and post-treatment. RESULTS: 35.0 % of women in the pregnancy program and 41.6 % in the postnatal program completed all 3 lessons, with lower pre-treatment depression symptom severity significantly associated with increased likelihood of perinatal program completion. Both iCBT programs were associated with medium pre- to post-treatment effect size reductions in generalised anxiety symptom severity (gs = 0.63 and 0.71), depression symptom severity (gs = 0.58 and 0.64), and psychological distress (gs = 0.52 and 0.60). LIMITATIONS: Lack of control group and long-term follow-up, as well as detailed information on nature of the sample (e.g., health status, relationship status). Additionally, the sample was limited to Australian residents. CONCLUSION: iCBT for perinatal anxiety and depression was associated with significant symptom improvement. Current findings support the use of iCBT in perinatal populations and its integration within routine healthcare provision.

Comparing the effectiveness of existing anxiety treatment options among patients evaluated for chest pain and anxiety in the emergency department setting: Study protocol for the PACER pragmatic randomized comparative effectiveness trial.

BACKGROUND: Anxiety disorders are a common underlying cause of symptoms among low-risk chest pain patients evaluated in the emergency department setting. However, anxiety is often undiagnosed and undertreated in any setting, and causes considerable functional impairment to work, family, and social life. OBJECTIVES: The Patient-Centered Treatment of Anxiety after Low-Risk Chest Pain in the Emergency Room (PACER) study is a pragmatic randomized trial to test the comparative effectiveness of existing anxiety treatments of graduated intensities and determine what options work best for patient subgroups based on anxiety severity and other comorbidities. METHODS: The PACER trial will enroll 375 emergency department patients with low-risk chest pain and anxiety (GAD-7 score ≥ 8) and randomize them to either: 1) referral to primary care with enhanced care coordination, 2) online self-administered cognitive behavioral therapy with guided peer support, or 3) therapist-administered cognitive behavior therapy. Outcomes include anxiety symptoms (primary) as well as physical symptom burden, depression symptoms, functional impairment, ED recidivism, and occurrence of major adverse cardiac events. Statistical analyses will be conducted primarily using linear mixed models to perform a repeated measures analysis of patient-reported outcomes, assessed at 3, 6, 9, and 12-month follow-ups. DISCUSSION: PACER is an innovative and pragmatic clinical trial that will compare the effectiveness of several evidence-based telecare-delivered treatments for anxiety. Results have the potential to inform clinical guidelines for evaluation and management of low-risk chest pain patients and promote adoption of findings in ED departments across the country.

Predictors of ultrasound-guided peripheral intravenous catheter failure: A secondary analysis of existing trial data.

OBJECTIVES: Ultrasound-guided (US) peripheral intravenous catheters (PIVC) have a high failure rate with many failing prior to completion of therapy. Risk factors associated with catheter failure are poorly delineated. This study aimed to assess risk factors related to catheter failure including patient, procedure, catheter, and vein characteristics to further elucidate which variables may impact catheter longevity. METHODS: This was a secondary analysis using an existing trial dataset that primarily compared survival of two catheters: a standard long (SL) and an ultra-long (UL) US PIVC. Adult emergency room patients with difficult intravenous access at a tertiary care suburban academic center were study participants. Kaplan-Meier was employed to estimate the median catheter survival time. Cox regression univariable and multivariable analyses were used to evaluate the primary outcome of catheter survival. RESULTS: Among 257 subjects, 63% of PIVCs survived until completion of therapy. In a multivariable Cox regression model, length of catheter in vein >2.75 cm (adjusted hazard ratio [aHR] 0.58, 95% confidence interval [CI] 0.37-0.90, p = 0.01) was associated with improved survival. First stick success decreased the risk of catheter failure (aHR 0.68, 95% CI 0.44-1.06, p = 0.09) but was not statistically significant. Factors associated with the increased risk of catheter failure included: depth of vein >1.2 cm (aHR 1.68, 95% CI 1.06-2.66, p = 0.03) and PIVC placement in right extremity (aHR 1.64, 95% CI 1.07-2.51, p = 0.02). CONCLUSIONS: This study demonstrated that catheter length in vein (>2.75 cm) was associated with improved US PIVC survival highlighting the value of longer catheters in US PIVC survival. Choosing targets in the non-dominant extremity with shallower depths (⩽1.2 cm) may also increase catheter survival.

The Uptake and Effectiveness of a Multidisciplinary Online Program for Managing Chronic Pain before and During the COVID-19 Pandemic.

OBJECTIVES: Societal and health system pressures associated with the coronavirus disease 2019 (COVID-19) pandemic exacerbated the burden of chronic pain and limited access to pain management services for many. Online multidisciplinary pain programs offer an effective and scalable treatment option, but have not been evaluated within the context of COVID-19. This study aimed to investigate the uptake and effectiveness of the Reboot Online chronic pain program before and during the first year of the COVID-19 pandemic. METHODS: Retrospective cohort analyses were conducted on routine service users of the Reboot Online program, comparing those who commenced the program during the COVID-19 pandemic (March 2020-March 2021), to those prior to the pandemic (April 2017-March 2020). Outcomes included the number of course registrations; commencements; completion rates; and measures of pain severity, interference, self-efficacy, pain-related disability, and distress. RESULTS: Data from 2,585 course users were included (n = 1138 pre-COVID-19 and n = 1,447 during-COVID-19). There was a 287% increase in monthly course registrations during COVID-19, relative to previously. Users were younger, and more likely to reside in a metropolitan area during COVID-19, but initial symptom severity was comparable. Course adherence and effectiveness were similar before and during COVID-19, with moderate effect size improvements in clinical outcomes post-treatment (g = 0.23-0.55). DISCUSSION: Uptake of an online chronic pain management program substantially increased during the COVID-19 pandemic. Program adherence and effectiveness were similar pre- and during-COVID. These findings support the effectiveness and scalability of online chronic pain management programs to meet increasing demand.

The Effect of Adjunct Telephone Support on Adherence and Outcomes of the Reboot Online Pain Management Program: Randomized Controlled Trial.

BACKGROUND: Internet-based treatment programs present a solution for providing access to pain management for those unable to access clinic-based multidisciplinary pain programs. Attrition from internet interventions is a common issue. Clinician-supported guidance can be an important feature in web-based interventions; however, the optimal level of therapist guidance and expertise required to improve adherence remains unclear. OBJECTIVE: The aim of this study is to evaluate whether augmenting the existing Reboot Online program with telephone support by a clinician improves program adherence and effectiveness compared with the web-based program alone. METHODS: A 2-armed, CONSORT (Consolidated Standards of Reporting Trials)-compliant, registered randomized controlled trial with one-to-one group allocation was conducted. It compared a web-based multidisciplinary pain management program, Reboot Online, combined with telephone support (n=44) with Reboot Online alone (n=45) as the control group. Participants were recruited through web-based social media and the This Way Up service provider network. The primary outcome for this study was adherence to the Reboot Online program. Adherence was quantified through three metrics: completion of the program, the number of participants who enrolled into the program, and the number of participants who commenced the program. Data on adherence were collected automatically through the This Way Up platform. Secondary measures of clinical effectiveness were also collected. RESULTS: Reboot Online combined with telephone support had a positive effect on enrollment and commencement of the program compared with Reboot Online without telephone support. Significantly more participants from the Reboot Online plus telephone support group enrolled (41/44, 93%) into the course than those from the control group (35/45, 78%; χ21=4.2; P=.04). Furthermore, more participants from the intervention group commenced the course than those from the control group (40/44, 91% vs 27/45, 60%, respectively; χ21=11.4; P=.001). Of the participants enrolled in the intervention group, 43% (19/44) completed the course, and of those in the control group, 31% (14/45) completed the course. When considering the subgroup of those who commenced the program, there was no significant difference between the proportions of people who completed all 8 lessons in the intervention (19/40, 48%) and control groups (14/27, 52%; χ21=1.3; P=.24). The treatment efficacy on clinical outcome measures did not differ between the intervention and control groups. CONCLUSIONS: Telephone support improves participants' registration, program commencement, and engagement in the early phase of the internet intervention; however, it did not seem to have an impact on overall course completion or efficacy. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12619001076167; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12619001076167.

COVID-19 related differences in the uptake and effects of internet-based cognitive behavioural therapy for symptoms of obsessive-compulsive disorder.

BACKGROUND: The impacts of COVID-19 for people with obsessive-compulsive disorder (OCD) may be considerable. Online cognitive behavioural therapy (iCBT) programmes provide scalable access to psychological interventions, although the effectiveness of iCBT for OCD during COVID-19 has not been evaluated. AIM: This study investigated the uptake and effectiveness of iCBT for OCD (both self- and clinician-guided courses) during the first 8 months of the pandemic in Australia (March to October 2020) and compared outcomes with the previous year. METHOD: 1,343 adults (824/1343 (61.4%) female, mean age 33.54 years, SD = 12.00) commenced iCBT for OCD (1061 during the pandemic and 282 in the year before) and completed measures of OCD (Dimensional Obsessive-Compulsive Scale) and depression (Patient Health Questionaire-9) symptom severity, psychological distress (Kessler-10), and disability (WHO Disability Assessment Schedule) pre- and post-treatment. RESULTS: During COVID-19, there was a 522% increase in monthly course registrations compared with the previous year, with peak uptake observed between April and June 2020 (a 1191% increase compared with April to June 2019). OCD and depression symptom severity were similar for the COVID and pre-COVID groups, although COVID-19 participants were more likely to enrol in self-guided courses (versus clinician-guided). In both pre- and during-COVID groups, the OCD iCBT course was associated with medium effect size reductions in OCD (g = 0.65-0.68) and depression symptom severity (g = 0.56-0.65), medium to large reductions in psychological distress (g = 0.77-0.83) and small reductions in disability (g = 0.35-.50). CONCLUSION: Results demonstrate the considerable uptake of online psychological services for those experiencing symptoms of OCD during COVID-19 and highlight the scalability of effective digital mental health services.

The uptake and outcomes of Internet-based cognitive behavioural therapy for health anxiety symptoms during the COVID-19 pandemic.

BACKGROUND: Internet cognitive behavioural therapy (iCBT) for health anxiety has demonstrated efficacy but has not been evaluated during the COVID-19 pandemic. This study presents the first evaluation of the uptake and outcomes of iCBT for health anxiety during the COVID-19 pandemic. METHODS: THIS WAY UP is an Australian digital mental health service which delivers iCBT interventions to community members. We compared the uptake of THIS WAY UP's iCBT course for health anxiety in an Australian adult sample who started the course before the pandemic (12th September 2019-11 th March 2020) to during the pandemic (12th March to 11th June 2020). The course was accessible to Australian adults over 18 years old, with no inclusion criteria. Outcomes included course registrations and commencements, lesson and course completion, and self-reported health anxiety (Short Health Anxiety Inventory), depression (Patient Health Questionnaire 9-item) and distress (Kessler-10). RESULTS: From March to June 2020, we observed significant increases in course registrations (N = 238 vs N = 1057); and course commencements (N = 126 vs. N = 778). Large, significant improvements in health anxiety (g = 0.89), and distress (K10: g = 0.91), and medium improvements in depression (g = 0.55) were found. Course completion during COVID was 30.5%. CONCLUSIONS: iCBT improved health anxiety during the COVID-19 pandemic, and provides scalable intervention that can address increased demands for mental health services in the community.

A tale of two countries: Increased uptake of digital mental health services during the COVID-19 pandemic in Australia and New Zealand.

BACKGROUND: Digital mental health services (DMHS) provide highly accessible psychological supports and interventions that can supplement existing mental health services. Concerns about the mental health impact of the COVID-19 pandemic have been widespread and provide a unique impetus to examine the utility and responsivity of DMHS. This study examined the service utilisation and user characteristics of two DMHS (THIS WAY UP and Just a Thought) in Australia and New Zealand before and during the early pandemic period in these countries (March to June 2020). METHODS: Service use indices (website visits, course registrations and prescriptions, clinician registrations) were compared across different time periods before (12, 6 and 3 months) and during the pandemic in Australia and New Zealand. The demographic and clinical characteristics of course registrants (anxiety and depression symptom severity and psychological distress) were also compared across the pre- and during-COVID periods. RESULTS: Comparing pre-COVID to during-COVID time periods, we observed substantial increases across all service use indices in both DMHS (increases of >100% on the majority of service use indices). For example, in the 3 months prior to the pandemic, 2806 people registered for a THIS WAY UP course and 1907 people registered for a Just a Thought course, whereas 21,872 and 5442 registered for a THIS WAY UP and Just a Thought course, respectively, during the first 3 months of the COVID pandemic. Slight differences in the demographic and clinical profiles of course registrants were found between pre- and during-COVID time periods, with limited evidence of elevated anxiety and depression symptom severity in the COVID period. CONCLUSIONS: Following the outbreak of COVID-19 in Australia and New Zealand, the volume of users accessing DMHS increased yet the demographic and clinical characteristics of course registrants remained stable. Results underscore how nimble and scalable DMHS can be during periods of high demand.

The uptake and effectiveness of online cognitive behaviour therapy for symptoms of anxiety and depression during COVID-19.

BACKGROUND: The mental health impacts of COVID-19 have been considerable with many individuals experiencing significant anxiety and depression. Online cognitive behavioural therapy (iCBT) programs provide scalable access to psychological interventions, however the effectiveness of these programs during the pandemic has not been investigated. This study examined the uptake and effectiveness of iCBT for symptoms of anxiety and depression during the first eight months of the pandemic in Australia (March- October 2020) and compared outcomes to the 12 months prior to COVID-19. METHODS: 6,132 adults commenced iCBT (5,074 during the pandemic and 1,058 in the year before) and completed measures of anxiety and depression symptom severity, and psychological distress pre- and post-treatment. RESULTS: In the COVID-19 period, we observed a 504% increase in the number of monthly course registrations compared to the year prior (with a peak increase of 1,138% between April and June 2020). Baseline anxiety and depression symptom severity were similar for the COVID and pre-COVID groups. Prior to and during the pandemic, the iCBT course was associated with large effect size reductions in anxiety (g = 0.94-1.18) and depression (g = 0.92-1.12) symptom severity, as well as psychological distress (g = 1.08-1.35). LIMITATIONS: lack of control group and long-term follow-up, as well as lack of detailed information about course users (e.g., health status and life context). CONCLUSION: Results indicate the considerable increase in demand for psychological support during the COVID-19 pandemic in Australia and demonstrate the effectiveness and scalability of iCBT for symptoms of anxiety and depression.

Comorbid personality difficulties are not associated with poorer outcomes for online cognitive behaviour therapy for symptoms of anxiety and depression.

Little is known about the prevalence and impact on treatment of comorbid personality disorders for adults undertaking online cognitive behaviour therapy (internet-delivered or internet-based cognitive behaviour therapy (iCBT)) for anxiety and depressive disorders. This study explored how common comorbid personality difficulties were in a large sample of consecutive patients (N = 1 132) seeking iCBT for their symptoms of anxiety and depression in routine care settings. Patients completed the Standardized Assessment of Personality-abbreviated Scale Self-Report prior to commencing an iCBT programme, as well as completing assessments of anxiety and depression symptom severity and psychological distress pre-iCBT and post-iCBT. Consistent with previous studies, a high proportion of the sample (62.6%) reported experiencing comorbid personality difficulties. However, comorbid personality difficulties were not significantly associated with poorer treatment adherence or higher post-treatment symptom severity or psychological distress (controlling for baseline symptom severity, demographic characteristics and treatment variables). Current findings support an inclusive approach to iCBT provision where comorbid personality difficulties do not appear to be a contraindication for treatment. © 2021 John Wiley & Sons, Ltd.

Impact of around-the-clock in-house cardiology fellow coverage on door-to-balloon time in an academic medical center.

OBJECTIVES: To assess if a change in our cardiology fellowship program impacted our ST elevation myocardial infarction (STEMI) program. BACKGROUND: Fellows covering the cardiac care unit were spending excessive hours in the hospital while on call, resulting in increased duty hours violations. A night float fellow system was started on July 1, 2012, allowing the cardiac care unit fellow to sign out to a night float fellow at 5:30 pm. The night float fellow remained in-house until the morning. METHODS: We performed a retrospective study assessing symptom onset to arrival, arterial access to first device, and door-to-balloon (D2B) times, in consecutive STEMI patients presenting to our emergency department before and after initiation of the night float fellow system. RESULTS: From 2009 to 2013, 208 STEMI patients presented to our emergency department and underwent primary percutaneous coronary intervention. There was no difference in symptom onset to arrival (150±102 minutes vs 154±122 minutes, p=0.758), arterial access to first device (12±8 minutes vs 11±7 minutes, p=0.230), or D2B times (50±32 minutes vs 52±34 minutes, p=0.681) during regular working hours. However, there was a significant decrease in D2B times seen during off-hours (72±33 minutes vs 49±15 minutes, p=0.007). There was no difference in in-hospital mortality (11% vs 8%, p=0.484) or need for intra-aortic balloon pump placement (7% vs 8%, p=0.793). CONCLUSION: In academic medical centers, in-house cardiology fellow coverage during off-hours may expedite care of STEMI patients.

Initial electrocardiogram as determinant of hospital course in ST elevation myocardial infarction.

BACKGROUND: A proportion of patients with ST elevation myocardial infarction (STEMI) have an initial electrocardiogram (ECG) that is nondiagnostic and are definitively diagnosed on a subsequent ECG. Our aim was to assess whether patients with a nondiagnostic initial ECG are different than those with a diagnostic initial ECG. METHODS: We collected demographic, ECG, medication, angiographic, and in-hospital clinical outcome data in consecutive patients undergoing primary percutaneous coronary intervention for STEMI at our institution from June 2009 to June 2013. RESULTS: A total of 334 patients were included, 285 (85%) diagnosed on the initial ECG and 49 (15%) on a subsequent ECG. Patients with a nondiagnostic initial ECG had more comorbidities including prior congestive heart failure (14% vs. 3%, p < .001), coronary artery disease (47% vs. 24%, p = .001), diabetes (37% vs. 16%, p = .001), and hyperlipidemia (55% vs. 40%, p = .048); higher rates of chronic medication use including aspirin (47% vs. 27%, p = .005), beta-blocker (47% vs. 22%, p < .001), and statins (53% vs. 28%, p = .001); longer door-to-balloon times (106 min vs. 45 min, p < .001); lower peak troponin levels (25 ng/ml vs. 50 ng/ml, p = .004), longer diagnostic ECG to balloon times (84 min vs. 75 min, p = .006); and higher rates of a patent infarct-related artery on baseline angiography (41% vs. 24%, p = .018) which remained significant in a multivariable logistic regression model. CONCLUSIONS: Approximately one in seven STEMI patients had an initial ECG that was nondiagnostic for STEMI. These patients had more comorbidities, higher rates of medication use, and received delayed intervention (even after the diagnosis was definitive).

Severe Sepsis due to Clostridium perfringens Bacteremia of Urinary Origin: A Case Report and Systematic Review.

Clostridium perfringens bacteremia is an uncommon yet serious clinical syndrome that typically arises from a gastrointestinal source. However, clinicians should consider nongastrointestinal sources as well. We present a rare case of C. perfringens bacteremia of urinary origin that required surgical intervention for definitive treatment. A 61-year-old male presented with acute nausea and vomiting, altered mental status, and chronic diarrhea. His physical exam revealed right costovertebral tenderness and his laboratory work-up revealed acute renal failure. Percutaneous blood cultures grew C. perfringens. Cross-sectional imaging revealed a right-sided ureteral stone with hydronephrosis, which required nephrostomy placement. On placement of the nephrostomy tube, purulent drainage was identified and Gram stain of the drainage revealed Gram-variable rods. A urinary source of C. perfringens was clinically supported. Although it is not a common presentation, nongastrointestinal sources such as a urinary source should be considered in C. perfringens bacteremia because failure to recognize a nongastrointestinal source can delay appropriate treatment, which may include surgical intervention.