Mindfulness-Based Stress Reduction vs Escitalopram for the Treatment of Adults With Anxiety Disorders: A Randomized Clinical Trial.

Importance: Anxiety disorders are common, highly distressing, and impairing conditions. Effective treatments exist, but many patients do not access or respond to them. Mindfulness-based interventions, such as mindfulness-based stress reduction (MBSR) are popular and can decrease anxiety, but it is unknown how they compare to standard first-line treatments. Objective: To determine whether MBSR is noninferior to escitalopram, a commonly used first-line psychopharmacological treatment for anxiety disorders. Design, Setting, and Participants: This randomized clinical trial (Treatments for Anxiety: Meditation and Escitalopram [TAME]) included a noninferiority design with a prespecified noninferiority margin. Patients were recruited between June 2018 and February 2020. The outcome assessments were performed by blinded clinical interviewer at baseline, week 8 end point, and follow-up visits at 12 and 24 weeks. Of 430 individuals assessed for inclusion, 276 adults with a diagnosed anxiety disorder from 3 urban academic medical centers in the US were recruited for the trial, and 208 completed the trial. Interventions: Participants were 1:1 randomized to 8 weeks of the weekly MBSR course or the antidepressant escitalopram, flexibly dosed from 10 to 20 mg. Main Outcomes and Measures: The primary outcome measure was anxiety levels as assessed with the Clinical Global Impression of Severity scale (CGI-S), with a predetermined noninferiority margin of -0.495 points. Results: The primary noninferiority sample consisted of 208 patients (102 in MBSR and 106 in escitalopram), with a mean (SD) age of 33 (13) years; 156 participants (75%) were female; 32 participants (15%) were African American, 41 (20%) were Asian, 18 (9%) were Hispanic/Latino, 122 (59%) were White, and 13 (6%) were of another race or ethnicity (including Native American or Alaska Native, more than one race, or other, consolidated owing to low numbers). Baseline mean (SD) CGI-S score was 4.44 (0.79) for the MBSR group and 4.51 (0.78) for the escitalopram group in the per-protocol sample and 4.49 (0.77) vs 4.54 (0.83), respectively, in the randomized sample. At end point, the mean (SD) CGI-S score was reduced by 1.35 (1.06) for MBSR and 1.43 (1.17) for escitalopram. The difference between groups was -0.07 (0.16; 95% CI, -0.38 to 0.23; P = .65), where the lower bound of the interval fell within the predefined noninferiority margin of -0.495, indicating noninferiority of MBSR compared with escitalopram. Secondary intent-to-treat analyses using imputed data also showed the noninferiority of MBSR compared with escitalopram based on the improvement in CGI-S score. Of patients who started treatment, 10 (8%) dropped out of the escitalopram group and none from the MBSR group due to adverse events. At least 1 study-related adverse event occurred for 110 participants randomized to escitalopram (78.6%) and 21 participants randomized to MBSR (15.4%). Conclusions and Relevance: The results from this randomized clinical trial comparing a standardized evidence-based mindfulness-based intervention with pharmacotherapy for the treatment of anxiety disorders found that MBSR was noninferior to escitalopram. Trial Registration: ClinicalTrials.gov Identifier: NCT03522844.

Online SMART Recovery mutual support groups: Characteristics and experience of adults seeking treatment for methamphetamine compared to those seeking treatment for other addictive behaviours.

INTRODUCTION: The COVID-19 pandemic prompted the transition of Australian Self-Management and Recovery Training (SMART) Recovery mutual support groups to virtual delivery. This study examined the self-reported experience of online SMART Recovery groups for people seeking support for methamphetamine use (alone or in combination with other behaviours) compared to those who did not endorse methamphetamine use as a reason for seeking support. METHODS: An online survey invitation was embedded in the post-group exit page. Items assessed participant demographic characteristics, experience, engagement and perceived contribution of the online group to recovery. Unique responses (n = 1414) were analysed using chi-square. RESULTS: After alcohol, methamphetamine use was the second most common behaviour to prompt online SMART Recovery group attendance (n = 205, 14.5%). People attending for methamphetamine use were more likely to endorse multiple addictive behaviours (n = 137, 66.8% vs. n = 371, 30.7%, p < 0.001). Irrespective of whether people attended for methamphetamine use or not, participant ratings of experience, engagement and perceived contribution to recovery were positive and largely comparable. People attending for methamphetamine use were significantly less likely to set a 7-day plan (72.7% vs. 81.9%; χ2  = 9.47, p = 0.002). DISCUSSION AND CONCLUSIONS: Findings support the acceptability of online SMART Recovery groups for people experiencing addictive behaviours, including methamphetamine use. To maximise the benefits of these groups, further evidence on how best to support people to develop a change plan within a time-limited, online group setting is needed. Online mutual support groups may help to reach and support people who might not otherwise engage in treatment and support, including people who use methamphetamine.

Supporting people affected by problematic alcohol, substance use and other behaviours under pandemic conditions: A pragmatic evaluation of how SMART recovery Australia responded to COVID-19.

BACKGROUND: The COVID-19 pandemic prompted rapid, reflexive transition from face-to-face to online healthcare. For group-based addiction services, evidence for the impact on service delivery and participant experience is limited. METHODS: A 12-month (plus 2-month follow-up) pragmatic evaluation of the upscaling of online mutual-help groups by SMART Recovery Australia (SRAU) was conducted using The Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework. Data captured by SRAU between 1st July 2020 and 31st August 2021 included participant questionnaires, Zoom Data Analytics and administrative logs. RESULTS: Reach: The number of online groups increased from just 6 pre-COVID-19 to 132. These groups were delivered on 2786 (M = 232.16, SD = 42.34 per month) occasions, to 41,752 (M = 3479.33, SD = 576.34) attendees. EFFECTIVENESS: Participants (n = 1052) reported finding the online group meetings highly engaging and a positive, recovery supportive experience. 91 % of people with experience of face-to-face group meetings rated their online experience as equivalent or better. Adoption: Eleven services (including SRAU) and five volunteers delivered group meetings for the entire 12-months. IMPLEMENTATION: SRAU surpassed their goal of establishing 100 groups. Maintenance: The average number of meetings delivered [t(11.14) = -1.45, p = 0.1737] and attendees [t(1.95) = -3.28, p = 0.1880] per month were maintained across a two-month follow-up period. CONCLUSIONS: SRAU scaled-up the delivery of online mutual-help groups in response to the COVID-19 pandemic. Findings support the accessibility, acceptability and sustainability of delivering SMART Recovery mutual-help groups online. Not only are these findings important in light of the global pandemic and public safety, but they demonstrate the potential for reaching and supporting difficult and under-served populations.

Adapting Peer Researcher Facilitated Strategies to Recruit People Receiving Mental Health Services to a Tobacco Treatment Trial.

Introduction: One of the most challenging aspects of conducting intervention trials among people who experience severe mental illness (SMI) and who smoke tobacco, is recruitment. In our parent "QuitLink" randomized controlled trial (RCT), slower than expected peer researcher facilitated recruitment, along with the impact of COVID-19 pandemic restrictions, necessitated an adaptive recruitment response. The objectives of the present study were to: (i) describe adaptive peer researcher facilitated recruitment strategies; (ii) explore the effectiveness of these strategies; (iii) investigate whether recruitment strategies reached different subgroups of participants; and (iv) examine the costs and resources required for implementing these strategies. Finally, we offer experience-based lessons in a Peer Researcher Commentary. Methods: People were included in the RCT if they smoked at least 10 cigarettes a day and were accessing mental health support from the project's two partnering mental health organizations in Victoria, Australia. The majority of people accessing these services will have been diagnosed with SMI. Recruitment occurred over 2 years. We began with peer facilitated recruitment strategies delivered face-to-face, then replaced this with direct mail postcards followed by telephone contact. In the final 4 months of the study, we began online recruitment, broadening it to people who smoked and were accessing support or treatment (including from general practitioners) for mental health and/or alcohol or other drug problems, anywhere in the state of Victoria. Differences between recruitment strategies on key participant variables were assessed. We calculated the average cost per enrolee of the different recruitment approaches. Results: Only 109 people were recruited from a target of 382: 29 via face-to-face (March 2019 to April 2020), 66 from postcards (May 2020 to November 2020), and 14 from online (November to December 2020 and January to March 2021) strategies. Reflecting our initial focus on recruiting from supported independent living accommodation facilities, participants recruited face-to-face were significantly more likely to be living in partially or fully supported independent living (n = 29, <0.001), but the samples were otherwise similar. After the initial investment in training and equipping peer researchers, the average cost of recruitment was AU$1,182 per participant-~US$850. Face-to-face recruitment was the most expensive approach and postcard recruitment the least (AU$1,648 and AU$928 per participant). Discussion: Peer researcher facilitated recruitment into a tobacco treatment trial was difficult and expensive. Widely dispersed services and COVID-19 restrictions necessitated non-face-to-face recruitment strategies, such as direct mail postcards, which improved recruitment and may be worthy of further research. Clinical Trial Registration: The trial is registered with ANZCTR (www.anzctr.org.au): ACTRN12619000244101 prior to the accrual of the first participant and updated regularly as per registry guidelines. The trial sponsor was the University of Newcastle, NSW, Australia.

Robotics for neuroendovascular intervention: Background and primer.

The simultaneous growth of robotic-assisted surgery and telemedicine in recent years has only been accelerated by the recent coronavirus disease 2019 pandemic. Robotic assistance for neurovascular intervention has garnered significant interest due to opportunities for tele-stroke models of care for remote underserved areas. Lessons learned from medical robots in interventional cardiology and neurosurgery have contributed to incremental but vital advances in medical robotics despite important limitations. In this article, we discuss robot types and their clinical justification and ethics, as well as a general overview on available robots in thoracic/abdominal surgery, neurosurgery, and cardiac electrophysiology. We conclude with current clinical research in neuroendovascular intervention and a perspective on future directions.

Posterior reversible encephalopathy syndrome (PRES): Another imaging manifestation of COVID-19.

Neuroimaging manifestations of COVID-19 are being reported with increasing frequency with recent reports of associated atypical leukoencephalopathies. We add to this literature by describing a COVID-19 + patient who demonstrated imaging findings typical for posterior reversible encephalopathy syndrome (PRES). The inflammatory syndrome associated with novel corona virus infection has shown markedly increased levels of cytokines and inflammatory markers. This has also been described in a proposed mechanism for PRES, where elevated inflammatory markers result in endothelial injury causing interstitial fluid extravasation typical of PRES. We expect that other cases of PRES will be observed in this population given the scope of the Covid-19 pandemic.