"One of those things the student is left to do". Student midwives' experience of infant feeding education. A phenomenological study.

AIM/OBJECTIVE: To explore final year student midwives' experiences of breastfeeding education and clinical experience during their three year pre-registration midwifery degree course. BACKGROUND: Despite an increasing research base about what helps or hinders breastfeeding, there is a dramatic drop in breastfeeding prevalence within the first six weeks of birth. Breastfeeding support and education have been identified as influencing factors associated with breastfeeding prevalence, yet there is a paucity of evidence exploring infant feeding education for pre-registration student midwives. DESIGN: Qualitative data was gathered using semi-structured interviews with seventeen final year midwifery students in a Higher Education Institution in the North of England. METHODS: Interviews were audio recorded, transcribed verbatim, and analysed using thematic analysis. RESULTS: Three core themes were identified: The Mentor-Student Relationship, Midwives and student midwives' attitudes towards breastfeeding and Theory-Practice Disassociation. University-based input provided them with underpinning knowledge but provided little opportunity to develop skills. Attitudes towards breastfeeding were predominantly negative, and these negative descriptions were frequently linked by students to time constraints and workload pressures. The relationship between students and mentors had a direct impact on students' development of breastfeeding support skills and confidence: students who had mentors who were enthusiastic about their role in facilitating learning in clinical practice were confident in supporting women with infant feeding. However, many students described the hospital environment as too busy for infant feeding skills teaching and guidance. CONCLUSIONS: Although few participants were dissatisfied with how their pre-registration midwifery education prepared them for clinical practice in general, the majority would have liked more opportunities to support women with infant feeding in complex and challenging cases, both in University and in clinical practice. There is a need for midwifery students to be provided with a variety of educational experiences such as theoretical classroom-based learning, simulation-based learning, peer learning, clinical care practice and direct service user engagement. These learning experiences need to include artificial feeding and breastfeeding.

High dose psilocybin is associated with positive subjective effects in healthy volunteers.

AIM: The aim of the current study was to investigate the relationship between escalating higher doses of psilocybin and the potential psilocybin occasioned positive subjective effects. METHODS: Healthy participants ( n=12) were given three escalating doses of oral psilocybin (0.3 mg/kg; 0.45 mg/kg; 0.6 mg/kg) or (18.8-36.6 mg; 27.1-54.0 mg; 36.3-59.2 mg) a minimum of four weeks apart in a supervised setting. Blood and urine samples, vital signs, and electrocardiograms were obtained. Subjective effects were assessed using the Mystical Experience Questionnaire and Persisting Effects Questionnaire. RESULTS: There was a significant linear dose-related response in Mystical Experience Questionnaire total score and the transcendence of time and space subscale, but not in the rate of a complete mystical experience. There was also a significant difference between dose 3 compared to dose 1 on the transcendence of time and space subscale, while no dose-related differences were found for Mystical Experience Questionnaire total scores or rate of a mystical experience. Persisting Effects Questionnaire positive composite scores 30 days after completion of the last dose were significantly higher than negative composite scores. Persisting Effects Questionnaire results revealed a moderate increase in sense of well-being or life satisfaction on average that was associated with the maximum Mystical Experience Questionnaire total score. Pharmacokinetic measures were associated with dose but not with Mystical Experience Questionnaire total scores or rate of a mystical experience. CONCLUSIONS: High doses of psilocybin elicited subjective effects at least as strong as the lower doses and resulted in positive persisting subjective effects 30 days after, indicating that a complete mystical experience was not a prerequisite for positive outcomes.

Initial examination of characteristics of patients who are high utilizers of an established primary care behavioral health consultation service.

Obective: Although much has been studied regarding high-utilizing patients of medical services, no studies have been published regarding high-utilizing patients of integrated primary care behavioral health (PCBH) services. The primary purpose of the current study was to examine characteristics of high-utilizing patients of PCBH services and model adherence. The secondary purpose was to describe the process of conducting this research by clinicians in integrated care. METHOD: Data were obtained from electronic health records retrospectively for the study's time period, 2007-2013, for the sample of all patients who met with the behavioral health consultation team during that time. Variables include demographics, diagnoses, involvement in additional services, and scores on a patient-complexity scale for a subset of patients. Chi-square analyses, t tests and logistic regression analyses were performed. RESULTS: The results demonstrate significant associations between key demographic characteristics, use of population-based augmentation services (i.e., consulting psychiatry, care management, substance-abuse consulting), and high-utilizing status. Model adherence was maintained over time. Logistic regression analysis, controlling for high-utilizing status and number of visits, demonstrated a significant relationship between more complex diagnostic categories and behavioral health issues. DISCUSSION: There are differences between high-utilizing patients and nonhigh-utilizing patients suggestive of increased clinical severity and appropriate use of services while maintaining PCBH model integrity. The use of the population-based augmentation services is associated with high-utilizer status, and reflects the ability of these services to target those patients who most need the clinical care. (PsycINFO Database Record

Pharmacokinetics of Escalating Doses of Oral Psilocybin in Healthy Adults.

INTRODUCTION: Psilocybin is a psychedelic tryptamine that has shown promise in recent clinical trials for the treatment of depression and substance use disorders. This open-label study of the pharmacokinetics of psilocybin was performed to describe the pharmacokinetics and safety profile of psilocybin in sequential, escalating oral doses of 0.3, 0.45, and 0.6 mg/kg in 12 healthy adults. METHODS: Eligible healthy adults received 6-8 h of preparatory counseling in anticipation of the first dose of psilocybin. The escalating oral psilocybin doses were administered at approximately monthly intervals in a controlled setting and subjects were monitored for 24 h. Blood and urine samples were collected over 24 h and assayed by a validated liquid chromatography-tandem mass spectrometry (LC-MS/MS) assay for psilocybin and psilocin, the active metabolite. The pharmacokinetics of psilocin were determined using both compartmental (NONMEM) and noncompartmental (WinNonlin) methods. RESULTS: No psilocybin was found in plasma or urine, and renal clearance of intact psilocin accounted for less than 2% of the total clearance. The pharmacokinetics of psilocin were linear within the twofold range of doses, and the elimination half-life of psilocin was 3 h (standard deviation 1.1). An extended elimination phase in some subjects suggests hydrolysis of the psilocin glucuronide metabolite. Variation in psilocin clearance was not predicted by body weight, and no serious adverse events occurred in the subjects studied. CONCLUSIONS: The small amount of psilocin renally excreted suggests that no dose reduction is needed for subjects with mild-moderate renal impairment. Simulation of fixed doses using the pharmacokinetic parameters suggest that an oral dose of 25 mg should approximate the drug exposure of a 0.3 mg/kg oral dose of psilocybin. Although doses of 0.6 mg/kg are in excess of likely therapeutic doses, no serious physical or psychological events occurred during or within 30 days of any dose. CLINICAL TRIALS IDENTIFIER: NCT02163707.

The effect of bundling medication-assisted treatment for opioid addiction with mHealth: study protocol for a randomized clinical trial.

BACKGROUND: Opioid dependence has devastating and increasingly widespread consequences and costs, and the most common outcome of treatment is early relapse. People who inject opioids are also at disproportionate risk for contracting the human immunodeficiency virus (HIV) and hepatitis C virus (HCV). This study tests an approach that has been shown to improve recovery rates: medication along with other supportive services (medication-assisted treatment, or MAT) against MAT combined with a smartphone innovation called A-CHESS (MAT + A-CHESS). METHODS/DESIGN: This unblinded study will randomly assign 440 patients to receive MAT + A-CHESS or MAT alone. Eligible patients will meet criteria for having an opioid use disorder of at least moderate severity and will be taking methadone, injectable naltrexone, or buprenorphine. Patients with A-CHESS will have smartphones for 16 months; all patients will be followed for 24 months. The primary outcome is the difference between patients in the two arms in percentage of days using illicit opioids during the 24-month intervention. Secondary outcomes are differences between patients receiving MAT + A-CHESS versus MAT in other substance use, quality of life, retention in treatment, health service use, and, related to HIV and HCV, screening and testing rates, medication adherence, risk behaviors, and links to care. We will also examine mediators and moderators of the effects of MAT + A-CHESS. We will measure variables at baseline and months 4, 8, 12, 16, 20, and 24. At each point, patients will respond to a 20- to 30-min phone survey; urine screens will be collected at baseline and up to twice a month thereafter. We will use mixed-effects to evaluate the primary and secondary outcomes, with baseline scores functioning as covariates, treatment condition as a between-subject factor, and the outcomes reflecting scores for a given assessment at the six time points. Separate analyses will be conducted for each outcome. DISCUSSION: A-CHESS has been shown to improve recovery for people with alcohol dependence. It offers an adaptive and extensive menu of services and can attend to patients nearly as constantly as addiction does. This suggests the possibility of increasing both the effectiveness of, and access to, treatment for opioid dependence. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02712034 . Registered on 14 March 2016.

Implementing an mHealth system for substance use disorders in primary care: a mixed methods study of clinicians' initial expectations and first year experiences.

BACKGROUND: Millions of Americans need but don't receive treatment for substance use, and evidence suggests that addiction-focused interventions on smart phones could support their recovery. There is little research on implementation of addiction-related interventions in primary care, particularly in Federally Qualified Health Centers (FQHCs) that provide primary care to underserved populations. We used mixed methods to examine three FQHCs' implementation of Seva, a smart-phone app that offers patients online support/discussion, health-tracking, and tools for coping with cravings, and offers clinicians information about patients' health tracking and relapses. We examined (a) clinicians' initial perspectives about implementing Seva, and (b) the first year of implementation at Site 1. METHODS: Prior to staggered implementation at three FQHCs (Midwest city in WI vs. rural town in MT vs. metropolitan NY), interviews, meetings, and focus groups were conducted with 53 clinicians to identify core themes of initial expectations about implementation. One year into implementation at Site 1, clinicians there were re-interviewed. Their reports were supplemented by quantitative data on clinician and patient use of Seva. RESULTS: Clinicians anticipated that Seva could help patients and make behavioral health appointments more efficient, but they were skeptical that physicians would engage with Seva (given high caseloads), and they were uncertain whether patients would use Seva. They were concerned about legal obligations for monitoring patients' interactions online, including possible "cries for help" or inappropriate interactions. One year later at Site 1, behavioral health care providers, rather than physicians, had incorporated Seva into patient care, primarily by discussing it during appointments. Given workflow/load concerns, only a few key clinicians monitored health tracking/relapses and prompted outreach when needed; two researchers monitored the discussion board and alerted the clinic as needed. Clinician turnover/leave complicated this approach. Contrary to clinicians' initial concerns, patients showed sustained, mutually supportive use of Seva, with few instances of misuse. CONCLUSIONS: Results suggest the value of (a) focusing implementation on behavioral health care providers rather than physicians, (b) assigning a few individuals (not necessarily clinicians) to monitor health tracking, relapses, and the discussion board, (c) anticipating turnover/leave and having designated replacements. Patients showed sustained, positive use of Seva. TRIAL REGISTRATION: ClinicalTrials.gov ( NCT01963234 ).

Consulting psychiatry within an integrated primary care model.

After implementation of an integrated consulting psychiatry model and psychology services within primary care at a federally qualified health center, patients have increased access to needed mental health services, and primary care clinicians receive the support and collaboration needed to meet the psychiatric needs of the population.