The impact on mental health practitioners of the death of a patient by suicide: A systematic review.

There is a growing body of research investigating the impact on mental health professionals of losing a patient through suicide. However, the nature and extent of the impact is unclear. This systematic review synthesizes both quantitative and qualitative studies in the area. The aim was to review the literature on the impact of losing a patient through suicide with respect to both personal and professional practice responses as well as the support received. A search of the major psychological and medical databases was conducted, using keywords including suicide, patient, practitioner, and impact, which yielded 3,942 records. Fifty-four studies were included in the final narrative synthesis. Most common personal reactions in qualitative studies included guilt, shock, sadness, anger, and blame. Impact on professional practice included self-doubt and being more cautious and defensive in the management of suicide risk. As quantitative study methodologies were heterogeneous, it was difficult to make direct comparisons across studies. However, 13 studies (total n = 717 practitioners) utilized the Impact of Event Scale, finding that between 12% and 53% of practitioners recorded clinically significant scores. The need for training that is focused on the impact of suicides, and the value placed upon informal support was often cited. The experience of losing a patient through suicide can have a significant impact on mental health professionals, both in terms of their personal reactions and subsequent changes to professional practice. The negative impact, however, may be moderated by cultural and organisational factors and by the nature of support available.

The HXD95: a modified Bassett-type hydrothermal diamond-anvil cell for in situ XRD experiments up to 5 GPa and 1300 K.

A new diamond-anvil cell apparatus for in situ synchrotron X-ray diffraction measurements of liquids and glasses, at pressures from ambient to 5 GPa and temperatures from ambient to 1300 K, is reported. This portable setup enables in situ monitoring of the melting of complex compounds and the determination of the structure and properties of melts under moderately high pressure and high temperature conditions relevant to industrial processes and magmatic processes in the Earth's crust and shallow mantle. The device was constructed according to a modified Bassett-type hydrothermal diamond-anvil cell design with a large angular opening (θ = 95°). This paper reports the successful application of this device to record in situ synchrotron X-ray diffraction of liquid Ga and synthetic PbSiO3 glass to 1100 K and 3 GPa.

Clinical burden of severe respiratory syncytial virus infection during the first 2 years of life in children born between 2000 and 2011 in Scotland.

National data from Scotland (all births from 2000 to 2011) were used to estimate the burden associated with respiratory syncytial virus hospitalisation (RSVH) during the first 2 years of life. RSVHs were identified using the International Classification of Diseases 10th Revision codes. Of 623,770 children, 13,362 (2.1%) had ≥ 1 RSVH by 2 years, with the overall rate being 27.2/1000 (16,946 total RSVHs). Median age at first RSVH was 137 days (interquartile range [IQR] 62-264), with 84.3% of admissions occurring by 1 year. Median length of stay was 2 (IQR 1-4) days and intensive care unit (ICU) admission was required by 4.3% (727) for a median 5 (IQR 2-8) days. RSVHs accounted for 6.9% (5089/73,525) of ICU bed days and 6.2% (64,395/1,033,121) of overall bed days (5370/year). RSVHs represented 8.5% (14,243/168,205) of all admissions between October and March and 14.2% (8470/59,535) between December and January. RSVH incidence ranged from 1.7 to 2.5%/year over the study period. Preterms (RSVH incidence 5.2%), and those with congenital heart disease (10.5%), congenital lung disease (11.2%), Down syndrome (14.8%), cerebral palsy (15.5%), cystic fibrosis (12.6%), and neuromuscular disorders (17.0%) were at increased risk of RSVH.Conclusions: RSV causes a substantial burden on Scottish paediatric services during the winter months.What is known:• Respiratory syncytial virus (RSV) is a leading cause of childhood hospitalisation.What is new:• This 12-year study is the first to estimate the burden of RSV hospitalisation (RSVH) in Scotland and included all live births from 2000 to 2011 and followed > 600,000 children until 2 years old.• The overall RSVH rate was 27.2/1000 children, with 2.1% being hospitalised ≥ 1 times.• RSVHs accounted for 6.2% of all inpatient bed days, which rose to 14.2% during the peak months of the RSV season (December-January), equating to over 1400 hospitalisations and nearly 5500 bed days each year.

Patient referral from primary care to psychological therapy services: a cohort study.

BACKGROUND: Improving Access to Psychological Therapy (IAPT) services in England offer psychological therapy for patients with mental health issues such as depression and anxiety disorders. OBJECTIVE: How are primary care patients referred to IAPT, to what degree does this correlate with subsequent attendance, and how is the referral process perceived by patients? METHODS: Retrospective analysis of medical records covering June 2018-June 2019 in seven general practices servicing 96 000 patients, to identify and survey patients with anxiety and/or depression. RESULTS: Records of 6545 patients were appraised; 2612 patients were deemed suitable for IAPT intervention by the GP. Of those, 1424 (55%) attended at least one IAPT appointment whereas 1188 (45%) did not. These 'attender' and 'non-attender' cohorts did not differ in age, gender or level of deprivation; neither did GP advice to self-refer rather than making a direct GP referral influence the attendance rate. The most common reasons for IAPT non-attendance include symptom improvement (22%), lack of belief in psychotherapy effectiveness (16%) or a patient feeling too unwell to either refer themselves or attend (12%). CONCLUSIONS: Neither certain age or gender, nor the mode of patient referral to IAPT is associated with eventual attendance. Future research is indicated to identify in more detail if any specific mental health conditions are more likely to lead to non-attendance. Furthermore, there may be scope for a targeted approach for subgroups of patients, e.g. those who indicate they are feeling mentally too unwell, to enable them to attend IAPT screening and therapy appointments.

Self-practice/self-reflection as an alternative to personal training-therapy in cognitive behavioural therapy training: A qualitative analysis.

INTRODUCTION: The study examined the qualitative impact and credibility of self-practice/self-reflection (SP/SR). METHODS: Nineteen participants reflected on the self-practice of cognitive behavioural therapy techniques. Written reflections were analysed using inductive thematic analysis. RESULTS: Two superordinate themes (a) Personal-self and (b) Therapist-self, with themes and subthemes emerged. CONCLUSION: The themes found equivalents in existing goals of traditional therapists' training-therapy. Though brief, SP/SR may be a credible alternative/adjunctive training-therapy.

Training therapists to work with people with intellectual disability in Improving Access to Psychological Therapies (IAPT) services.

BACKGROUND: Current policy in the England suggests that people with intellectual disabilities should, where possible, access mainstream mental health services; this should include access to mainstream therapy services. It is likely that mainstream therapists will need training and support to work with people with intellectual disabilities. METHOD: Sixty-eight therapists working in an English Improving Access to Psychological Therapies (IAPT) service received one- or 2-day training on working with people with intellectual disabilities. Measures of confidence, general therapeutic self-efficacy and attitudes to people with intellectual disabilities' use of mainstream mental health services were completed pre-training, post-training and at 3-month follow-up; at which time, 12 participants were interviewed about the impact of the training on their practice. RESULTS: There was a significant positive change in all measures immediately post-training which was maintained at 3-month follow-up. CONCLUSIONS: Training considerations for mainstream therapists who may work with people with intellectual disabilities are discussed.

The Role of Practice Research Networks (PRN) in the Development and Implementation of Evidence: The Northern Improving Access to Psychological Therapies PRN Case Study.

Practice research networks (PRNs) can support the implementation of evidence based practice in routine services and generate practice based evidence. This paper describes the structure, processes and learning from a new PRN in the Improving Access to Psychological Therapies programme in England, in relation to an implementation framework and using one study as a case example. Challenges related to: ethics and governance processes; communications with multiple stakeholders; competing time pressures and linking outcome data. Enablers included: early tangible outputs and impact; a collaborative approach; engaging with local research leads; clarity of processes; effective dissemination; and committed leadership.

Identifying bacterial predictors of honey bee health.

Non-targeted approaches are useful tools to identify new or emerging issues in bee health. Here, we utilise next generation sequencing to highlight bacteria associated with healthy and unhealthy honey bee colonies, and then use targeted methods to screen a wider pool of colonies with known health status. Our results provide the first evidence that bacteria from the genus Arsenophonus are associated with poor health in honey bee colonies. We also discovered Lactobacillus and Leuconostoc spp. were associated with healthier honey bee colonies. Our results highlight the importance of understanding how the wider microbial population relates to honey bee colony health.

The Development of a Measure of Confidence in Delivering Therapy to People with Intellectual Disabilities.

UNLABELLED: Current policy in UK health services emphasizes that, where possible, people with intellectual disabilities should access the same services as people without intellectual disabilities. One of the barriers to this is the confidence of clinicians and therapists. In this paper, we report on the development of a scale to describe the confidence of therapists in working with people with intellectual disabilities (the Therapy Confidence Scale-Intellectual Disabilities [TCS-ID]). One-hundred and eighty-one therapists who provided talking therapies but who did not work primarily with people with intellectual disabilities completed the scale; 43 people completed the scale twice for test-retest reliability purposes. One-hundred and seven people also completed a scale of general therapy self-efficacy. The TCS-ID has a single factor structure accounting for 62% of the variance, Cronbach's alpha for the scale is 0.93 and test-retest reliability is 0.83. There are significant differences in confidence based upon participants experience in working with people with intellectual disabilities and their therapeutic orientation, and there is a significant association between the TCS-ID and the General Therapy Self-efficacy Scale. Sixty clinicians working in mainstream mental health services received training on adapting their therapeutic approaches to meet the needs of people with intellectual disabilities. The TCS-ID was used pre-training and post-training and demonstrated a significant increase in confidence for all group. We suggest that the scale has good psychometric properties and can be used to develop an understanding of the impact of training for mainstream therapist in working with people with intellectual disabilities. KEY PRACTITIONER MESSAGE: There is increasing emphasis on people with intellectual disabilities receiving services from mainstream mental health services. There is no research describing the experiences and outcomes of people with intellectual disabilities receiving mainstream talking therapy services. The confidence that clinicians have in working with people with intellectual disabilities may be a barrier to them receiving mainstream services. The Therapy Confidence Scale-Intellectual Disabilities is a psychometrically sound scale for measuring the confidence of therapists in working with people with intellectual disabilities and is a useful outcome measure for training clinicians to work with people with intellectual disabilities.

A measurable impact of a self-practice/self-reflection programme on the therapeutic skills of experienced cognitive-behavioural therapists.

The need for effective training methods for enhancing cognitive-behavioural therapist competency is not only relevant to new therapists but also to experienced therapists looking to retain and further enhance their skills. Self-practice/self-reflection (SP/SR) is a self-experiential cognitive-behavioural therapy (CBT) training programme, which combines the experience of practicing CBT methods on oneself with structured reflection on the implications of the experience for clinical practice. In order to build on previous qualitative studies of SP/SR, which have mainly focused on trainee CBT therapists, the aim of the current study was to quantify the impact of SP/SR on the therapeutic skills of an experienced cohort of CBT therapists. Fourteen CBT therapists were recruited to participate in an SP/SR programme specifically adapted for experienced therapists. In the context of a quasi-experimental design including multiple baselines within a single-case methodology, therapists provided self-ratings of technical cognitive therapy skill and interpersonal empathic skill at four critical time points: baseline, pre-SP/SR and post-SP/SR and follow-up. Analysis of programme completers (n = 7) indicated that SP/SR enhances both technical skill and interpersonal therapeutic skill. Further intention-to-treat group (n = 14) analyses including both those who left the programme early (n = 3) and those who partially completed the programme (n = 4) added to the robustness of findings with respect to technical cognitive therapy skills but not interpersonal empathic skills. It was concluded that SP/SR, as a training and development programme, could offer an avenue to further therapeutic skill enhancement in already experienced CBT therapists.

Exploring the impact on primary care mental health practitioners of the death of a patient by suicide: An IPA study.

OBJECTIVES: There have been numerous qualitative studies into the impact of the death of a patient by suicide on clinicians, but the majority of studies have focussed on psychiatrists and psychologists, primarily in inpatient or secondary care settings. To date, little has been done to explore the impact of such deaths on other mental health practitioners working in primary care, such as those working in Improving Access to Psychological Therapies (IAPT) services. DESIGN: This qualitative study used purposive sampling and adopted an interpretative phenomenological analysis (IPA) methodology. METHOD: All participants had experienced the death of a patient in their role as a practitioner in an IAPT service. Seven practitioners were recruited from services across the North of England. Semi-structured, one-hour telephone interviews were audio recorded and then transcribed verbatim. RESULTS: Analysis of the transcripts identified a number of themes, which were represented in the majority of cases. Specifically, the analyses yielded four superordinate themes: (1) feeling shocked and upset about the death of a patient; (2) attempting to understand the causes of the suicide; (3) learning from the tragic event; and (4) reflections on what helped in coping with the tragic event. The emotional responses of shock, upset, guilt and fear of blame by IAPT practitioners following the death of a patient through suicide is consistent with that found in studies of other mental health practitioners. CONCLUSIONS: It is hoped that the current study will help raise awareness amongst primary care mental health practitioners, services and training centres, of the impact of losing a patient to suicide and will encourage them to consider how best to prepare and support practitioners in this eventuality. Recommendations include raising awareness of the potential for patient suicide in primary care services, providing clarity on the individualised support available and on the requirements of investigations.

The Adaptation of a Measure of Confidence in Assessing, Formulating, and Managing Suicide Risk.

Background: To date little has been done to evaluate the effectiveness of suicide risk formulation training. Aims: We aimed to investigate the psychometric properties of a new scale measuring clinicians' confidence in assessing, formulating, and managing suicide risk. Method: A total of 128 mental health practitioners from an UK National Health Service Trust completed the scale. Of them, 85 from an Improving Access to Psychological Therapies service did so before and after training in Risk Assessment, Formulation, and Management (RAFM); 28 practitioners from the Older Adults service also completed the measure. For test-retest analysis, a further 15 completed the scale again 1 week after baseline without attending any training. Of the training group, 52 (61%) completed the measure at the 6-month follow-up. Results: Analysis indicated a single-factor structure, good test-retest reliability, and statistically significant increases in confidence between pre- and posttraining and between pretraining and 6 month follow-up. Cohen's effect size values suggest a moderate-to-large effect. Limitations: The relatively small sample sizes indicate that this study should be considered a preliminary investigation of a new measure, which warrants further replication. Conclusion: This measure could be useful in gauging practitioners' confidence in the RAFM approach and in evaluating and developing training.

Dynamic prediction of psychological treatment outcomes: development and validation of a prediction model using routinely collected symptom data.

BACKGROUND: Common mental disorders can be effectively treated with psychotherapy, but some patients do not respond well and require timely identification to prevent treatment failure. We aimed to develop and validate a dynamic model to predict psychological treatment outcomes, and to compare the model with currently used methods, including expected treatment response models and machine learning models. METHODS: In this prediction model development and validation study, we obtained data from two UK studies including patients who had accessed therapy via Improving Access to Psychological Therapies (IAPT) services managed by ten UK National Health Service (NHS) Trusts between March, 2012, and June, 2018, to predict treatment outcomes. In study 1, we used data on patient-reported depression (Patient Health Questionnaire 9 [PHQ-9]) and anxiety (Generalised Anxiety Disorder 7 [GAD-7]) symptom measures obtained on a session-by-session basis (Leeds Community Healthcare NHS Trust dataset; n=2317) to train the Oracle dynamic prediction model using iterative logistic regression analysis. The outcome of interest was reliable and clinically significant improvement in depression (PHQ-9) and anxiety (GAD-7) symptoms. The predictive accuracy of the model was assessed in an external test sample (Cumbria Northumberland Tyne and Wear NHS Foundation Trust dataset; n=2036) using the area under the curve (AUC), positive predictive values (PPVs), and negative predictive values (NPVs). In study 2, we retrained the Oracle algorithm using a multiservice sample (South West Yorkshire Partnership NHS Foundation Trust, North East London NHS Foundation Trust, Cheshire and Wirral Partnership NHS Foundation Trust, and Cambridgeshire and Peterborough NHS Foundation Trust; n=42 992) and compared its performance with an expected treatment response model and five machine learning models (Bayesian updating algorithm, elastic net regularisation, extreme gradient boosting, support vector machine, and neural networks based on a multilayer perceptron algorithm) in an external test sample (Whittington Health NHS Trust; Barnet Enfield and Haringey Mental Health Trust; Pennine Care NHS Foundation Trust; and Humber NHS Foundation Trust; n=30 026). FINDINGS: The Oracle algorithm trained using iterative logistic regressions generalised well to external test samples, explaining up to 47·3% of variability in treatment outcomes. Prediction accuracy was modest at session one (AUC 0·59 [95% CI 0·55-0·62], PPV 0·63, NPV 0·61), but improved over time, reaching high prediction accuracy (AUC 0·81 [0·77-0·86], PPV 0·79, NPV 0·69) as early as session seven. The performance of the Oracle model was similar to complex (eg, including patient profiling variables) and computationally intensive machine learning models (eg, neural networks based on a multilayer perceptron algorithm, extreme gradient boosting). Furthermore, the predictive accuracy of a more simple dynamic algorithm including only baseline and index-session scores was comparable to more complex algorithms that included additional predictors modelling sample-level and individual-level variability. Overall, the Oracle algorithm significantly outperformed the expected treatment response model (mean AUC 0·80 vs 0·70, p<0·0001]). INTERPRETATION: Dynamic prediction models using sparse and readily available symptom measures are capable of predicting psychotherapy outcomes with high accuracy. FUNDING: University of Sheffield.

Negative regulation of the Hrp type III secretion system in Pseudomonas syringae pv. phaseolicola.

Many plant-pathogenic bacteria require type III secretion systems (T3SS) to cause disease in compatible hosts and to induce the hypersensitive response in resistant plants. T3SS gene expression is induced within the plant and responds to host and environmental factors. In Pseudomonas syringae, expression is downregulated by the Lon protease in rich medium and by HrpV under inducing conditions. HrpV acts as an anti-activator by binding HrpS. HrpG, which can also bind HrpV, has been reported to act as an anti-anti-activator. Previous studies have used mostly in vitro inducing conditions, different pathovars, and methodology. We have used single and double lon and hrpV mutants of P. syringae pv. phaseolicola 1448a, as well as strains ectopically expressing the regulators, to examine their role in coordinating expression of the T3SS. We applied real-time polymerase chain reaction to analyze gene expression both in vitro and in planta, and assessed bacterial fitness using competitive indices. Our results indicate that i) Lon downregulates expression of the hrp/hrc genes in all conditions, probably by constitutively degrading naturally unstable HrpR; ii) HrpV and HrpT downregulate expression of the hrp/hrc genes in all conditions; and iii) HrpG has an additional, HrpV-independent role, regulating expression of the hrpC operon.

Positive regulation of the Hrp type III secretion system in Pseudomonas syringae pv. phaseolicola.

Disease in compatible hosts and induction of the hypersensitive response in resistant plants by most plant-pathogenic bacteria require a functional type III secretion system (T3SS). Expression of T3SS genes responds to host and environmental factors and is induced within the plant. In Pseudomonas syringae, expression of the T3SS requires HrpL, which is transcriptionally upregulated by HrpR and HrpS. In some pathovars, expression of the hrpRS genes is upregulated by the GacA/S two-component system. Additionally, HrpA, the major component of the T3SS pilus, has also been linked to the regulation of the hrpRS gene expression. Previous studies concerning regulation of hypersensitive response and pathogenesis/hypersensitive response conserved (hrp/hrc) gene expression have used mostly in vitro inducing conditions, different pathovars, and methodology. Here, we analyze the roles of HrpL, GacA, and HrpA in the bean pathogen, using single, double, and triple mutants as well as strains ectopically expressing the regulators. We use real-time polymerase chain reaction analysis in vitro and in planta to quantify gene expression and competitive indices and other assays to assess bacterial fitness. Our results indicate that i) HrpL acts as a general virulence regulator that upregulates non-T3SS virulence determinants and downregulates flagellar function; ii) GacA modulates the expression of hrpL, and its contribution to virulence is entirely HrpL dependent; iii) there is a basal HrpL-independent expression of the T3SS genes in rich medium that is important for full activation of the system, maybe by keeping the system primed for rapid activation upon contact with the plant; and iv) HrpA upregulates expression of the T3SS genes and is essential to activate expression of the hrpZ operon upon contact with the plant.

Molecular microbiological characterization of preterm neonates at risk of bronchopulmonary dysplasia.

The role of infection in bronchopulmonary dysplasia (BPD) is unknown. We present an observational study of 55 premature infants born weighing less than 1.3 kg within two level III neonatal intensive care units. Endotracheal aspirates (ETA) and nasogastric aspirates (NGA) were studied with denaturing gradient gel electrophoresis (DGGE) profiling to elucidate the total bacterial community, and species-specific PCR was used to detect the presence of Mycoplasma hominis, Ureaplasma urealyticum, and Ureaplasma parvum. DGGE identified bacterial species in 59% of NGA and ETA samples combined. A diverse range of species were identified including several implicated in preterm labor. Species-specific PCR identified M. hominis in 25% of NGA and 11% of ETA samples. Among the 48 infants surviving up to 36 wk-postconceptual age, ordinal logistic regression showed the odds ratio for BPD or death where Ureaplasma was present/absent as 4.80 (95% CI 1.15-20.13). After adjusting for number of days ventilated, this was reduced to 2.04 (0.41-10.25). These data demonstrate how the combined use of DGGE and species-specific PCR identifies a high exposure in utero and around the time of birth to bacteria that might be causally related to preterm delivery and subsequent lung injury.

The occurrence of Melissococcus plutonius in healthy colonies of Apis mellifera and the efficacy of European foulbrood control measures.

European foulbrood (EFB) persists in England and Wales despite current treatment methods, all of which include feeding honey bee colonies with the antibiotic oxytetracycline (OTC). A large-scale field experiment was conducted to monitor a husbandry-based method, using comb replacement (known as Shook swarm), as a drug free EFB control option. The understanding of EFB epidemiology is limited, with little information on the presence of Melissococcus plutonius in disease free colonies. Additional samples were collected from diseased and disease free apiaries to identify symptomless infection. EFB reoccurrence was not significantly different between OTC and husbandry methods and real-time PCR data demonstrated that fewer Shook swarm treated colonies contained M. plutonius carryover to the Spring following treatment. Asymptomatic colonies from diseased apiaries showed an increased risk of testing positive for M. plutonius compared to asymptomatic colonies from disease free apiaries. The probability of a sample being symptomatic increased when a greater quantity of M. plutonius was detected in adult bees and larvae. The possibility of treating EFB as an apiary disease rather than a colony disease and the implications of a control strategy without antibiotics are discussed.

An Investigation Into the Factor Structure of the Attitudes to Suicide Prevention Scale.

Aim: The aim of this study was to investigate the factor structure of the Attitudes to Suicide Prevention Scale (ASPS). Method: The ASPS was distributed to all staff in a UK National Health Service Trust (N = 957). We conducted an exploratory factor analysis followed by a confirmatory factor analysis by splitting the data 60/40 into training and testing subsets. A multiple regression analysis was carried out to investigate whether the overall scale score varied as a function of professional role, age, and gender and whether respondents had completed suicide prevention training or not. Results: Two items displaying poor item-scale correlation were excluded from the factor analysis and a further item was excluded as it was based on different anchor points. For the remaining 11 items, no adequate factor structure emerged. The scale total demonstrated statistically significant differences in attitudes between staff groups (defined by attendance at suicide awareness or prevention training, by gender, and by level of patient contact), but not between groups defined by age range. Generally, however, there were positive attitudes across all Trust staff. Limitations: This study had a low response rate (24%) and was cross-sectional which limits the conclusions that could be drawn. Furthermore, other areas such as convergent validity and test-retest reliability were not examined. Conclusion: Our findings found no satisfactory factor structure for the ASPS. Further scale development would be beneficial.