Designing a primary care pharmacist-led review for people treated with opioids for persistent pain: a multi-method qualitative study.

BACKGROUND: Opioids are frequently prescribed for persistent non-cancer pain despite limited evidence of long-term effectiveness and risk of harm. Evidence-based interventions to address inappropriate opioid prescribing are lacking. AIM: To explore perspectives of people living with persistent pain to understand barriers and facilitators in reducing opioids in the context of a pharmacist-led primary care review, and identify review components and features for optimal delivery. DESIGN & SETTING: Primary care multi-method qualitative study. METHOD: Adults with experience of persistent pain and taking opioids participated in semi-structured interviews (n=15, 73% female) and an online discussion forum (n=31). The Theoretical Domains Framework (TDF) provided a framework for data collection and thematic analysis, involving deductive analysis to TDF domains, inductive analysis within-domains to generate subthemes, and subtheme comparison to form across-domain overarching themes. The behaviour change technique taxonomy v.1 and motivational behaviour change technique classification system were used to systematically map themes to behaviour change techniques to identify potential review components and delivery features. RESULTS: 32 facilitator and barrier subthemes for patients reducing opioids were identified across 13 TDF domains. These combined into six overarching themes: learning to live with pain, opioid reduction expectations, assuming a medical model, pharmacist-delivered reviews, pharmacist-patient relationship and patient engagement. Subthemes mapped to 21 unique behaviour change techniques, yielding 17 components and five delivery features for the proposed PROMPPT review. CONCLUSION: This study generated theoretically-informed evidence for design of a practice pharmacist-led PROMPPT review. Future research will test the feasibility and acceptability of the PROMPPT review and pharmacist training.

Pilot randomised controlled trial of a remotely delivered online intervention for adolescent mental health problems in India: lessons learned about low acceptability and feasibility during the COVID-19 pandemic.

BACKGROUND: 'POD Adventures' is a gamified problem-solving intervention delivered via smartphone app, and supported by non-specialist counsellors for a target population of secondary school students in India during the COVID-19 pandemic. AIMS: To evaluate the feasibility and acceptability of undertaking a randomised controlled trial of POD Adventures when delivered online with telephone support from counsellors. METHOD: We conducted a parallel, two-arm, individually randomised pilot-controlled trial with 11 secondary schools in Goa, India. Participants received either the POD Adventures intervention delivered over 4 weeks or usual care comprising information about local mental health services and national helplines. Outcomes were assessed at two timepoints: baseline and 6 weeks post-randomisation. RESULTS: Seventy-nine classroom sensitisation sessions reaching a total of 1575 students were conducted. Ninety-two self-initiated study referrals (5.8%) were received, but only 11 participants enrolled in the study. No intervention arm participants completed the intervention. Outcomes at 6 weeks were not available for intervention arm participants (n = 5), and only four control arm participants completed outcomes. No qualitative interviews or participant satisfaction measures were completed because participants could not be reached by the study team. CONCLUSIONS: Despite modifications to address barriers arising from COVID-19 restrictions, online delivery was not feasible in the study context. Low recruitment and missing feasibility and acceptability data make it difficult to draw conclusions about intervention engagement and indicative clinical outcomes. Prior findings showing high uptake, adherence and engagement with POD Adventures when delivered in a school-based context suggest that an online study and delivery posed the biggest barriers to study participation and engagement.

Problem Solving as an Active Ingredient in Indicated Prevention and Treatment of Youth Depression and Anxiety: An Integrative Review.

Problem solving is a common focus of psychological interventions for young people. However, existing evidence syntheses are relatively limited in their scope and conclusions. Taking a transdiagnostic approach and incorporating diverse sources of evidence, we examined the role of problem solving as an active ingredient for the indicated prevention and treatment of depression and anxiety in 14-24-year-olds. Three information sources were integrated using framework synthesis: (1) a systematic review of randomized controlled trials of problem solving; (2) a metasynthesis of qualitative evidence on the therapeutic experience of problem solving; and (3) consultations with a Youth Advisory Group. Intervention protocols that included problem solving and no more than one other specific component appeared to be effective for depression but not anxiety. Larger multicomponent interventions with a problem-solving element achieved moderate effect sizes for both conditions. There was no clear evidence that effectiveness varied by population characteristics, intervention formats, or contextual factors. Qualitative evidence and youth consultations highlighted positive views about the practicality, simplicity, and flexibility of problem solving. Converging sources also suggested changes in problem orientation as a key transdiagnostic process contributing to positive outcomes. Problem solving is a widely applicable therapeutic approach that can help young people with emotional problems to resolve specific stressors and lead to a more hopeful mindset about managing future challenges. Implications for practice are discussed.

A Guided Internet-Based Problem-Solving Intervention Delivered Through Smartphones for Secondary School Pupils During the COVID-19 Pandemic in India: Protocol for a Pilot Randomized Controlled Trial.

BACKGROUND: "POD Adventures" is a gamified mental health intervention delivered via a smartphone app and supported by counsellors for a target population of secondary school students in India. This paper describes the protocol for a pilot randomized controlled trial of a remotely delivered version of the intervention in the context of COVID-19 restrictions. OBJECTIVE: Our objectives are to assess the feasibility of research procedures and intervention delivery and to generate preliminary estimates of the effectiveness of the intervention to inform the sample size calculation of a full-scale trial. METHODS: We will conduct a parallel, 2-arm, individually randomized pilot controlled trial in 11 secondary schools in Goa, India. This pilot trial aims to recruit 70 participants with a felt need for psychological support. Participants will receive either the POD Adventures intervention delivered over 4 weeks or usual care comprising information about local mental health services and national helplines. Outcomes will be assessed at two timepoints: baseline and 6 weeks post randomization. RESULTS: The first participant was enrolled on January 28, 2021, and 6-week assessment completed on April 4, 2021. Owing to a second wave of the COVID-19 pandemic in India, schools in Goa were closed on April 22, 2021. Trial participants are currently receiving the intervention or completing follow-up assessments. CONCLUSIONS: This pilot trial will help understand the feasibility of implementing and evaluating a remotely delivered digital mental health intervention in a low-resource setting. Our findings will be used to design future trials that can address difficulties of accessing psychosocial support in-person and support wider efforts to scale up evidence-based mental health interventions for young people. TRIAL REGISTRATION: ClinicalTrials.gov NCT04672486; https://clinicaltrials.gov/ct2/show/NCT04672486. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/30339.

App-based guided problem-solving intervention for adolescent mental health: a pilot cohort study in Indian schools.

BACKGROUND: This paper describes the pilot evaluation of 'POD Adventures', a lay counsellor-guided problem-solving intervention delivered via a smartphone app in Indian secondary schools. OBJECTIVE: To test the feasibility and acceptability of POD Adventures for adolescents with a felt need for psychological support, and to explore the intervention's effects on self-reported mental health symptoms, prioritised problems, stress and well-being. METHODS: We used a mixed-methods pre-post cohort design. Participants were self-referred from grades 9-12 in two coeducational government-aided secondary schools in Goa, India. The intervention was delivered in two formats, 'mixed' (comprising individual and small group sessions) and 'group' (small group sessions only). FINDINGS: 248 participants enrolled in the study and 230 (92.7%) completed the intervention. Outcomes at 4 weeks showed significant improvements on all measures that were maintained at 12 weeks. Large effects were observed on problem severity scores (4 weeks, d=1.47; 12 weeks, d=1.53) while small to moderate effects were seen on mental health symptoms, stress and well-being. 22 students completed qualitative interviews about their experience of the intervention. Participants found POD Adventures easy to use, engaging and helpful in solving their problems. They were satisfied with the guidance provided by the counsellor irrespective of delivery format. CONCLUSIONS: POD Adventures was feasible to deliver with guidance from lay counsellors in Indian schools, acceptable to participants and associated with large improvements in problem severity and mental health symptom severity. CLINICAL IMPLICATIONS: POD Adventures has promise as an early intervention for adolescents with a felt need for psychological support in low-resource settings.

Design and Development of the "POD Adventures" Smartphone Game: A Blended Problem-Solving Intervention for Adolescent Mental Health in India.

Introduction: Digital technology platforms offer unparalleled opportunities to reach vulnerable adolescents at scale and overcome many barriers that exist around conventional service provision. This paper describes the design and development of POD Adventures, a blended problem-solving game-based intervention for adolescents with or at risk of anxiety, depression and conduct difficulties in India. This intervention was developed as part of the PRemIum for ADolEscents (PRIDE) research programme, which aims to establish a suite of transdiagnostic psychological interventions organized around a stepped care system in Indian secondary schools. Methods and Materials: Intervention development followed a person-centered approach consisting of four iterative activities: (i) review of recent context-specific evidence on mental health needs and preferences for the target population of school-going Indian adolescents, including a multiple stakeholder analysis of school counseling priorities and pilot studies of a brief problem-solving intervention; (ii) new focus group discussions with N = 46 student participants and N = 8 service providers; (iii) co-design workshops with N = 22 student participants and N = 8 service providers; and (iv) user-testing with N = 50 student participants. Participants were aged 12-17 years and recruited from local schools in New Delhi and Goa, including a subgroup with self-identified mental health needs (N = 6). Results: Formative data from existing primary sources, new focus groups and co-design workshops supported a blended format for delivering a brief problem-solving intervention, with counselors supporting use of a game-based app on "offline" smartphones. User-testing with prototypes identified a need for simplification of language, use of concrete examples of concepts and practice elements to enhance engagement. There were also indications that participants most valued relatability and interactivity within real-world stories with judicious support from an in-app guide. The final prototype comprised a set of interactive and gamified vignettes and a structured set of problem-solving questions to consolidate and generalize learning while encouraging real-world application. Discussion: Findings shaped the design of POD Adventures and its delivery as an open-access blended intervention for secondary school students with a felt need for psychological support, consistent with an early intervention paradigm. A randomized controlled trial is planned to evaluate processes and impacts of POD Adventures when delivered for help-seeking students in low-resource school settings.

What are young Indians saying about mental health? A content analysis of blogs on the It's Ok To Talk website.

OBJECTIVES: This study used thematic content analysis to examine submissions to a youth mental health website, www.itsoktotalk.in, in India. SETTING: We considered submissions made to the It's OK to Talk web platform during the first year of its operation (April 2017-March 2018), focusing specifically on website users based in India. PARTICIPANTS: We analysed 37 submissions by 33 authors aged 19-31 years (mean age 22 years) from seven Indian cities (New Delhi, Lucknow, Bengaluru, Mumbai, Pune, Hyderabad and Haryana). Eligible submissions were English-language first-person accounts of self-identified mental health problems, submitted in any media format for online publication by authors aged 18 years or older and who were based in India. Eight study participants were additionally involved in a focus group who contributed to the coding process and preparation of the final manuscript. RESULTS: Four themes were identified: (1) living through difficulties; (2) mental health in context; (3) managing one's mental health and (4) breaking stigma and sharing hope. Overall, the participants expressed significant feelings of distress and hopelessness as a result of their mental health problems; many described the context of their difficulties as resulting from personal histories or wider societal factors; a general lack of understanding about mental health; and widespread stigma and other negative attitudes. Most participants expressed a desire to overcome mental health prejudice and discrimination. CONCLUSIONS: Personal narratives offer a window into young people's self-identified priorities and challenges related to mental health problems and recovery. Such insights can inform antistigma initiatives and other public awareness activities around youth mental health.

A Qualitative Study of an Employment Scheme for Mentors with Lived Experience of Offending Within a Multi-Agency Mental Health Project for Excluded Young People.

The use of peer intervention schemes is increasingly popular within services for offending groups and there is growing evidence of their benefit for peers delivering the interventions. The current study explores staff and peer experiences of an employment scheme for peer mentors within a community project for young people involved in offending. Semi-structured interviews were conducted with full time staff (n=4) and peer mentors employed on the scheme (n=2). Thematic analysis revealed three themes of "Opportunity and Empowerment", "Supportive Processes" and "Role Definition and Structure". The results suggest that meaningful employment opportunities, with holistic support and processes for reflection and mentalisation of self and others, contribute to the personal and professional development of ex-offenders in peer mentoring roles.

Clinical Impact of Tumor DNA Repair Expression and T-cell Infiltration in Breast Cancers.

Impaired DNA repair drives mutagenicity, which increases neoantigen load and immunogenicity. We investigated the expression of proteins involved in the DNA damage response (ATM, Chk2), double-strand break repair (BRCA1, BLM, WRN, RECQL4, RECQL5, TOPO2A, DNA-PKcs, Ku70/Ku80), nucleotide excision repair (ERCC1), base excision repair (XRCC1, pol ß, FEN1, PARP1), and immune responses (CD8, PD-1, PD-L1, FOXP3) in 1,269 breast cancers and validated our findings in an independent estrogen receptor-negative (ER-) cohort (n = 279). Patients with tumors that expressed low XRCC1, low ATM, and low BRCA1 were not only associated with high numbers of CD8+ tumor-infiltrating lymphocytes, but were also linked to higher grades, high proliferation indexes, presence of dedifferentiated cells, ER- cells, and poor survival (all P ≤ 0.01). PD-1+ or PD-L1+ breast cancers with low XRCC1 were also linked to an aggressive phenotype that was high grade, had high proliferation indexes, contained dedifferentiated cells and ER- (all with P values ≤ 0.01), and poor survival (P = 0.00021 and P = 0.00022, for PD-1+ and PD-L1+ cancers, respectively) including in an independent ER- validation cohort (P = 0.007 and P = 0.047, respectively). We conclude that the interplay between DNA repair, CD8, PD-L1, and PD-1 can promote aggressive tumor phenotypes. XRCC1-directed personalization of immune checkpoint inhibitor therapy may be feasible and warrants further investigation in breast cancer. Cancer Immunol Res; 5(4); 292-9. ©2017 AACR.

Partial occlusion depiction and its relationship with field independence in children with ASD.

We report a study of the depiction of partial occlusion and its relationship with field independence (FI) in children with ASD. Nineteen ASD children and 29 TD children (5;6-10;0) attempted to copy two 3D occluded scenes, and also selected the 'best' depiction of these scenes in drawings by others. ASD children were not significantly different from controls on FI but were significantly delayed in partial occlusion drawing and selection, independently of chronological age (CA), nonverbal mental age (NVMA) and FI. The results suggest that the depiction of partial occlusion in children with ASD is not qualitatively distinct from that in children with typical development but is significantly and specifically delayed.