High fidelity dialectical behaviour therapy online: Learning from experienced practitioners.

Dialectical behaviour therapy (DBT) is an effective treatment for borderline personality disorder and other problems underpinned by difficulties with emotional regulation. The main components of DBT are skills training groups and individual therapy. The COVID-19 outbreak forced a rapid adaptation to online delivery, which largely mirrored face-to-face programmes using videoconferencing technology. This study aimed to elicit and describe the experiences and learning of therapists involved in providing high-fidelity DBT programmes via the Australian DBT Institute, which established an online delivery platform called DBT Assist™ prior to the COVID-19 pandemic. The report conforms with the consolidated criteria for reporting qualitative research (COREQ). Seven therapists were interviewed. Data were transcribed and analysed thematically. Delivering skills training online, either exclusively or in hybrid form (with face-to-face individual therapy), was acceptable and even preferable to therapists and clients. It was considered safe, the programme was associated with few non-completers, and it improved the accessibility of DBT to those who might otherwise not be able to engage in a face-to-face programme. Skills training utilized a 'flipped-learning' approach which improved the efficiency of online delivery. Other unique and helpful features of the online programme were described. The best outcomes associated with online DBT are likely to be achieved through careful adaptation to the online environment in accord with the principles of DBT rather than mirroring face-to-face processes. Further research is required to determine the efficacy of online therapy relative to face-to-face, and who might be best suited to different modes of delivery.

Towards online delivery of Dialectical Behaviour Therapy: A scoping review.

Dialectical Behaviour Therapy (DBT) programmes are often the only available treatment for people diagnosed with borderline personality disorder and were rapidly converted to online delivery during the COVID-19 pandemic. Limited research exists surrounding how the major elements of DBT are delivered in an online environment. This scoping review considered the operationalization of online delivery of DBT and its effectiveness. EBSCO host databases were searched using free text. Of 127 papers, 11 studies from 2010 to 2021 investigating online DBT for any clinical population were included in the review. A narrative synthesis of papers selected was undertaken. Seven articles reported results from five clinical trials (n = 437). Most adaptations mirrored face-to-face programmes although there was considerable variation in how therapy was facilitated. Attendance was reported to be greater online with comparable clinical improvements to face-to-face for those who remained in therapy. Additional challenges included managing risk, therapist preparedness and technology difficulties. Online delivery of DBT programmes is feasible and may be more accessible, acceptable and as safe and effective as face-to-face delivery. However, mirroring face to face delivery in an online environment may not be the most effective and efficient way to adapt DBT to online provision. Research is needed to identify areas which require further adaptation.

Validation of a novel online depression symptom severity rating scale: the R8 Depression.

BACKGROUND: An automated web-based assessment and monitoring system ( www.psynary.com ) has been developed to assist non-specialist clinicians in managing common mood and anxiety disorders. Psynary promotes the use of standardised outcome measures to assess symptom severity and optimise treatments with the aim of improving outcomes and enabling faster recovery. This paper analyses the results from two parallel studies in New Zealand and Japan (OptiMA-1 NZ and Japan) to assess the validity of the R8 Depression scale, one of the system's core outcome measures. METHODS: Clinical samples were recruited from a public secondary care and a private psychiatry clinic. Participants completed the outcome measures for the study via the online Psynary system. The R8 Depression scale is a 30-item questionnaire which includes all symptom domains covered in the ICD-10 classification of depression. The Patient Health Questionnaire (PHQ-9) was completed at the same time points as the R8 Depression, with a smaller sample also completing a paper-based Quick Inventory of Depressive Symptomatology (QIDS-SR16). Internal validity was quantified via Cronbach's alpha and Guttman lower bounds method. External validation against the PHQ-9 and QIDS used the Pearson's and Kendall's correlation coefficients. Severity categories were set using a multivariate regression model. RESULTS: 270 patients participated in the study and completed a maximum of 1 baseline and 5 reviews within a 90-day period, giving a total of 1124 assessments with the PHQ-9 also being completed in 1053 of these assessments. R8 Depression normative data was also collected from 204 non-clinical volunteers with 187 of these also completing the PHQ9. Internal reliability scores were all higher than 0.9 (n = 1328). There was overall good external validity when comparing the R8 Depression to the PHQ-9, with a correlation of 0.91 for the combined normative and clinical samples (n = 1240). CONCLUSIONS: The R8 Depression has been developed as a patient-rated outcome measure for depression for administration on an online system called "Psynary". It has high internal and external validity against current widely used scales. Further work is underway to determine the sensitivity to change of the R8 Depression.

Identifying the drivers and constraints to adoption of IPM among arable farmers in the UK and Ireland.

BACKGROUND: Arable crops in temperate climatic regions such as the UK and Ireland are subject to a multitude of pests (weeds, diseases and vertebrate/invertebrate pests) that can negatively impact productivity if not properly managed. Integrated pest management (IPM) is widely promoted as a sustainable approach to pest management, yet there are few recent studies assessing adoption levels and factors influencing this in arable cropping systems in the UK and Ireland. This study used an extensive farmer survey to address both these issues. RESULTS: Adoption levels of various IPM practices varied across the sample depending on a range of factors relating to both farm and farmer characteristics. Positive relationships were observed between IPM adoption and farmed area, and familiarity with IPM. Choice of pest control information sources was also found to be influential on farmer familiarity with IPM, with those who were proactive in seeking information from impartial sources being more engaged and reporting higher levels of adoption. CONCLUSION: Policies that encourage farmers to greater levels of engagement with their pest management issues and more proactive information seeking, such as through advisory professionals, more experienced peers through crop walks, open days and discussion groups should be strongly encouraged.

A value chain analysis of interventions to control production diseases in the intensive pig production sector.

Value chain analysis (VCA) calculated the financial effects on food chain actors of interventions to improve animal health and welfare in the intensive pig sector. Two interventions to reduce production diseases were studied. A generic chain diagram of linkages between stakeholders and value-added dimensions was designed. Data on structure and financial performance were collected for the sector. The production parameters and financial effects of the interventions were then described to illustrate impact on the supply chain. The effects of the interventions were also assessed at market level using economic welfare analysis. The sectors in Finland and the UK are small in farm numbers and few companies produced much of the output in a largely vertically-integrated structure. The most beneficial intervention in financial terms to farmers was improved hygiene in pig fattening (around +50% in gross margin). It was calculated to reduce the consumer price for pig meat by up to 5% when applied at large, whereas for improved management measures, it would reduce consumer price by less than 0.5%. However, the latter added value also through food quality attributes. We show that good hygiene and animal care can add value. However, evaluation of the financial and social viability of the interventions is needed to decide what interventions are adopted. The structure of supply chains influences which policy measures could be applied. Of the two interventions, improved pig hygiene had the largest potential to improve efficiency and reduce costs. The studied interventions can also provide new business opportunities to farms, slaughterhouses and food sector companies. More evidence is needed to support public policies and business decision-making in the sector. For this, evidence on consumer attitudes to production diseases is needed. Nevertheless, the study makes an important contribution by showing how improvements in health and welfare benefit the whole chain.

Measuring the unmeasurable? A method to quantify adoption of integrated pest management practices in temperate arable farming systems.

BACKGROUND: The impetus to adopt integrated pest management (IPM) practices has re-emerged in the last decade, mainly as a result of legislative and environmental drivers. However, a significant deficit exists in the ability to practically monitor and measure IPM adoption across arable farms; therefore, the aim of the project reported here was to establish a universal metric for quantifying adoption of IPM in temperate arable farming. This was achieved by: (i) identifying a set of key activities that contribute to IPM; (ii) weighting these in terms of their importance to the achievement of IPM using panels of expert stakeholders to create the metric (scoring system from 0 to 100 indicating level of IPM practised); (iii) surveying arable farmers in the UK and Ireland about their pest management practices; and (iv) measuring level of farmer adoption of IPM using the new metric. RESULTS: This new metric was found to be based on a consistent conception of IPM between countries and professional groups. The survey results showed that, although level of adoption of IPM practices varied over the sample, all farmers had adopted IPM to some extent (minimum 32.6 [corrected] points, mean score of 67.1), [corrected] but only 15 [corrected] of 225 farmers (5.8%) had adopted more than 67.1% [corrected] of what is theoretically possible, as measured by the new metric. CONCLUSION: We believe that this new metric would be a viable and cost-effective system to facilitate the benchmarking and monitoring of national IPM programmes in temperate zone countries with large-scale arable farming systems. © 2019 Society of Chemical Industry.

Consumer attitudes towards production diseases in intensive production systems.

Many members of the public and important stakeholders operating at the upper end of the food chain, may be unfamiliar with how food is produced, including within modern animal production systems. The intensification of production is becoming increasingly common in modern farming. However, intensive systems are particularly susceptible to production diseases, with potentially negative consequences for farm animal welfare (FAW). Previous research has demonstrated that the public are concerned about FAW, yet there has been little research into attitudes towards production diseases, and their approval of interventions to reduce these. This research explores the public's attitudes towards, and preferences for, FAW interventions in five European countries (Finland, Germany, Poland, Spain and the UK). An online survey was conducted for broilers (n = 789), layers (n = 790) and pigs (n = 751). Data were analysed by means of Kruskal-Wallis ANOVA, exploratory factor analysis and structural equation modelling. The results suggest that the public have concerns regarding intensive production systems, in relation to FAW, naturalness and the use of antibiotics. The most preferred interventions were the most "proactive" interventions, namely improved housing and hygiene measures. The least preferred interventions were medicine-based, which raised humane animal care and food safety concerns amongst respondents. The results highlighted the influence of the identified concerns, perceived risks and benefits on attitudes and subsequent behavioural intention, and the importance of supply chain stakeholders addressing these concerns in the subsequent communications with the public.

Folate Augmentation of Treatment--Evaluation for Depression (FolATED): randomised trial and economic evaluation.

BACKGROUND: Folate deficiency is associated with depression. Despite the biological plausibility of a causal link, the evidence that adding folate enhances antidepressant treatment is weak. OBJECTIVES: (1) Estimate the clinical effectiveness and cost-effectiveness of folic acid as adjunct to antidepressant medication (ADM). (2) Explore whether baseline folate and homocysteine predict response to treatment. (3) Investigate whether response to treatment depends on genetic polymorphisms related to folate metabolism. DESIGN: FolATED (Folate Augmentation of Treatment - Evaluation for Depression) was a double-blind and placebo-controlled, but otherwise pragmatic, randomised trial including cost-utility analysis. To yield 80% power of detecting standardised difference on the Beck Depression Inventory version 2 (BDI-II) of 0.3 between groups (a 'small' effect), FolATED trialists sought to analyse 358 participants. To allow for an estimated loss of 21% of participants over three time points, we planned to randomise 453. SETTINGS: Clinical - Three centres in Wales - North East Wales, North West Wales and Swansea. Trial management - North Wales Organisation for Randomised Trials in Health in Bangor University. Biochemical analysis - University Hospital of Wales, Cardiff. Genetic analysis - University of Liverpool. PARTICIPANTS: Four hundred and seventy-five adult patients presenting to primary or secondary care with confirmed moderate to severe depression for which they were taking or about to start ADM, and able to consent and complete assessments, but not (1) folate deficient, vitamin B12 deficient, or taking folic acid or anticonvulsants; (2) misusing drugs or alcohol, or suffering from psychosis, bipolar disorder, malignancy or other unstable or terminal illness; (3) (planning to become) pregnant; or (4) participating in other clinical research. INTERVENTIONS: Once a day for 12 weeks experimental participants added 5 mg of folic acid to their ADM, and control participants added an indistinguishable placebo. All participants followed pragmatic management plans initiated by a trial psychiatrist and maintained by their general medical practitioners. MAIN OUTCOME MEASURES: Assessed at baseline, and 4, 12 and 25 weeks thereafter, and analysed by 'area under curve' (main); by analysis of covariance at each time point (secondary); and by multi-level repeated measures (sensitivity analysis): Mental health - BDI-II (primary), Clinical Global Impression (CGI), Montgomery-Åsberg Depression Rating Scale (MADRS), UKU side effects scale, and Mini International Neuropsychiatric Interview (MINI) suicidality subscale; General health - UK 12-item Short Form Health Survey (SF-12), European Quality of Life scale - 5 Dimensions (EQ-5D); Biochemistry - serum folate, B12, homocysteine; Adherence - Morisky Questionnaire; Economics - resource use. RESULTS: Folic acid did not significantly improve any of these measures. For example it gained a mean of just 2.9 quality-adjusted life-days [95% confidence interval (CI) from -12.7 to 7.0 days] and saved a mean of just £48 (95% CI from -£292 to £389). In contrast it significantly reduced mental health scores on the SF-12 by 3.0% (95% CI from -5.2% to -0.8%). CONCLUSIONS: The FolATED trial generated no evidence that folic acid was clinically effective or cost-effective in augmenting ADM. This negative finding is consistent with improving understanding of the one-carbon folate pathway suggesting that methylfolate is a better candidate for augmenting ADM. Hence the findings of FolATED undermine treatment guidelines that advocate folic acid for treating depression, and suggest future trials of methylfolate to augment ADM. TRIAL REGISTRATION: Current Controlled Trials ISRCTN37558856. FUNDING: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 48. See the HTA programme website for further project information.

Enhancing rigour in the validation of patient reported outcome measures (PROMs): bridging linguistic and psychometric testing.

BACKGROUND: A strong consensus exists for a systematic approach to linguistic validation of patient reported outcome measures (PROMs) and discrete methods for assessing their psychometric properties. Despite the need for robust evidence of the appropriateness of measures, transition from linguistic to psychometric validation is poorly documented or evidenced. This paper demonstrates the importance of linking linguistic and psychometric testing through a purposeful stage which bridges the gap between translation and large-scale validation. FINDINGS: Evidence is drawn from a study to develop a Welsh language version of the Beck Depression Inventory-II (BDI-II) and investigate its psychometric properties. The BDI-II was translated into Welsh then administered to Welsh-speaking university students (n = 115) and patients with depression (n = 37) concurrent with the English BDI-II, and alongside other established depression and quality of life measures. A Welsh version of the BDI-II was produced that, on administration, showed conceptual equivalence with the original measure; high internal consistency reliability (Cronbach's alpha = 0.90; 0.96); item homogeneity; adequate correlation with the English BDI-II (r = 0.96; 0.94) and additional measures; and a two-factor structure with one overriding dimension. Nevertheless, in the student sample, the Welsh version showed a significantly lower overall mean than the English (p = 0.002); and significant differences in six mean item scores. This prompted a review and refinement of the translated measure. CONCLUSIONS: Exploring potential sources of bias in translated measures represents a critical step in the translation-validation process, which until now has been largely underutilised. This paper offers important findings that inform advanced methods of cross-cultural validation of PROMs.

Self-administered acupuncture as an alternative to deliberate self-harm: a feasibility study.

The aim of this mixed methods feasibility study was to demonstrate the acceptability, practicality, and safety of training patients who regularly use deliberate self harm (DSH) to self-administer acupuncture as an alternative coping skill for emotional distress. Ten adult patients with a diagnosis of emotionally unstable personality disorder who regularly self-harmed were recruited to the study following baseline assessment by a psychiatrist. An acupuncturist taught participants to self-acupuncture. During the 6-week intervention participants recorded their emotional distress, coping behaviors, thoughts, and feelings in a diary. Face-to-face interviews were used to explore participants' motives for DSH and their experience of acupuncture. Framework analysis was conducted on interview transcripts and diary entries to identify common themes. Mood at baseline and six weeks was measured using the BDI and changes in the use of coping behaviors and acupuncture were measured using diary entries. Subjects used acupuncture regularly through the six-week intervention and over this period there was a reduction in the frequency of DSH. Qualitative analysis identified two broad themes relating to the process and the effects of acupuncture. There was wide variation in the effects experienced by subjects which broadly mapped onto to the wide range of motives behind DSH. BDI scores showed a near significant reduction (p = 0.055) from 44.4. to 34.4 over the 6-week intervention. Patients presenting with deliberate self harm can be safely trained to self-administer acupuncture as an alternative coping skill. Acceptability and effectiveness may vary between patients depending on the complex motives underlying their self-harming behavior. While the pilot study was designed to explore the feasibility of the intervention, results from this limited sample suggest that use of self-administered acupuncture may reduce the frequency of self harming behavior and reduce emotional distress as measured using the BDI.

The effect of serotonergic and noradrenergic antidepressants on face emotion processing in depressed patients.

BACKGROUND: In healthy volunteers, exposure to antidepressants increases the recognition of positive face emotions and decreases recognition of negative emotions. It has been proposed that this may underlie therapeutic effects of antidepressants, but to date this has not been tested in clinical populations. METHOD: Recognition of facial emotions was measured at baseline (N=108) and after 2 (N=59) and 6 weeks (N=69) of treatment in depressed primary care patients who had been randomised to treatment with either citalopram (SSRI) or reboxetine (NaRI) in an open-label study. Changes in emotional processing were compared to clinical outcome after 6 weeks of treatment. RESULTS: Significant increases in recognition accuracy of disgust, happiness and surprise occurred by two-weeks of treatment with both antidepressants, and did not further change at 6 weeks. There was a significant correlation between the increased accuracy in recognition of happy faces over the first two-weeks of treatment and the clinical improvement after six-weeks of treatment. LIMITATIONS: There was no control group and changes over time may be due to practice effects. CONCLUSIONS: Antidepressants altered emotional processing in depressed patients with some similarities to the effects seen in healthy volunteers. The largest effect seen was increased recognition of disgust that may be specific to depressed patients. The correlation between increased accurate recognition of happy faces at two-weeks of treatment and clinical outcome at six-weeks of treatment suggests that early changes in emotional processing may underlie clinical response to antidepressants.

A community based survey of cognitive functioning, highway-code performance and traffic accidents in a cohort of older drivers.

BACKGROUND: The DVLA allows driving in early dementia contingent on regular medical assessment. GPs and psychiatrists require validated and accessible assessments. Some studies have suggested that cognitive testing has utility in the assessment of driving capacity in elderly drivers. One study raises the possibility of using a highway-code questionnaire as an adjunct to these tests. METHOD: Two hundred drivers over the age of 65 were randomly selected from two GP surgeries. Baseline assessment comprised completion of a Highway Code questionnaire (DPHC-98), the Mini Mental State Examination (MMSE) and an abbreviated version of the Alzheimer's Disease Assessment Scale Cognitive Subsection (EURO-ADAS). A history of road traffic accidents (RTAs) over the preceding 5 years was obtained. At 12-month follow-up interview driving status of the subject and occurrence of RTAs were recorded. Predictive power of DPHC-98 and cognitive testing with regards RTAs were examined through logistic regression analysis. RESULTS: Performance on the Highway Code questionnaire was identified as the only significant regression factor in the prediction of prospective RTAs. However, none of the logistic regression models were able to identify any drivers involved in RTAs either retrospectively or prospectively. CONCLUSION: Cognitive tests are not linked with risk of driving accidents in older adults in any useful way.

The incidence and prevalence of diabetes in patients with serious mental illness in North West Wales: two cohorts, 1875-1924 & 1994-2006 compared.

BACKGROUND: Against a background of interest in rates of diabetes in schizophrenia and related psychoses and claims that data from historical periods demonstrate a link that antedates modern antipsychotics, we sought to establish the rate of diabetes in first onset psychosis and subsequent prevalence in historical and contemporary cohorts. METHODS: Analysis of two epidemiologically complete databases of individuals admitted for mental illness. 3170 individuals admitted to the North Wales Asylum between 1875-1924 and tracked over 18,486 patient years and 394 North West Wales first admissions for schizophrenia and related psychoses between 1994 and 2006 and tracked after treatment. RESULTS: The prevalence of Type 2 diabetes among patients with psychoses at time of first admission in both historical and contemporary samples was 0%. The incidence of diabetes remained 0% in the historical sample throughout 15 years of follow-up but rose in the contemporary sample after 3, 5 and 6 years of treatment with an incidence rate double the expected population rate so that the 15 year prevalence is likely to be over 8%. CONCLUSION: No association was found between diabetes and serious mental illness, but there may be an association between diabetes and treatment.

Folate augmentation of treatment - evaluation for depression (FolATED): protocol of a randomised controlled trial.

BACKGROUND: Clinical depression is common, debilitating and treatable; one in four people experience it during their lives. The majority of sufferers are treated in primary care and only half respond well to active treatment. Evidence suggests that folate may be a useful adjunct to antidepressant treatment: 1) patients with depression often have a functional folate deficiency; 2) the severity of such deficiency, indicated by elevated homocysteine, correlates with depression severity, 3) low folate is associated with poor antidepressant response, and 4) folate is required for the synthesis of neurotransmitters implicated in the pathogenesis and treatment of depression. METHODS/DESIGN: The primary objective of this trial is to estimate the effect of folate augmentation in new or continuing treatment of depressive disorder in primary and secondary care. Secondary objectives are to evaluate the cost-effectiveness of folate augmentation of antidepressant treatment, investigate how the response to antidepressant treatment depends on genetic polymorphisms relevant to folate metabolism and antidepressant response, and explore whether baseline folate status can predict response to antidepressant treatment. Seven hundred and thirty patients will be recruited from North East Wales, North West Wales and Swansea. Patients with moderate to severe depression will be referred to the trial by their GP or Psychiatrist. If patients consent they will be assessed for eligibility and baseline measures will be undertaken. Blood samples will be taken to exclude patients with folate and B12 deficiency. Some of the blood taken will be used to measure homocysteine levels and for genetic analysis (with additional consent). Eligible participants will be randomised to receive 5 mg of folic acid or placebo. Patients with B12 deficiency or folate deficiency will be given appropriate treatment and will be monitored in the 'comprehensive cohort study'. Assessments will be at screening, randomisation and 3 subsequent follow-ups. DISCUSSION: If folic acid is shown to improve the efficacy of antidepressants, then it will provide a safe, simple and cheap way of improving the treatment of depression in primary and secondary care. TRIAL REGISTRATION: Current controlled trials ISRCTN37558856.

Prevalence and outcome of partial remission in depression.

The goal of treatment of major depression should be full remission. Many patients, however, fail to achieve or maintain symptom-free status. Residual depressive symptoms are common, even where there has been a robust response to antidepressant therapy. In clinical studies, approximately one-third of patients achieve a full remission, one-third experience a response and one-third are nonresponders. Partial remission is characterized by the presence of poorly defined residual symptoms. These symptoms typically include depressed mood, psychic anxiety, sleep disturbance, fatigue and diminished interest or pleasure. It is currently unclear which factors predict partial remission. However, it is clear that residual symptoms are powerful predictors of relapse, with relapse rates 3-6 times higher in patients with residual symptoms than in those who experience full remission. Residual symptoms are also associated with more medical and psychiatric visits, increased public assistance, disability benefits, thoughts of and attempts at suicide and chronicity. The risk of stroke and coronary events is also higher in patients with residual depressive symptoms. The substantial proportion of patients who achieve only partial remission has traditionally been neglected in antidepressant trials. Given that residual symptoms may relate, in part, to an incompatibility between patient and treatment, further research is needed to predict a better match. These symptoms are a clinically relevant state of illness, and the correct choice of initial antidepressant treatment should offer the greatest chance of achieving full remission.