Understanding the experiences of ketogenic metabolic therapy for people living with varying levels of depressive symptoms: a thematic analysis.

Background: Evidence suggests that a ketogenic diet (KD) may help to alleviate psychiatric symptoms, including depression and anxiety. Positive changes have been reported such as improvements in cognition, concentration, and sleep, a reduction in hunger, and an increase in well-being, energy, confidence, and resilience. This research aims to understand the impact of a non-calorie-restricted KD on depression and aspects of psychological well-being in those with varying degrees of depressive symptoms. Though there are a few studies directly exploring the experiences of those following a KD, this will be the first study to explore the narrative from a mental health and psychological well-being viewpoint. Method: A sample of nine participants who had followed a non-calorie restricted KD intervention of 50 g of carbohydrates or less per day for at least 12 weeks were recruited. Participants were split into 'healthy adults' group who had no to low depressive symptoms and 'depressive symptoms' group who had mild to moderate depressive symptoms. A reflexive thematic analysis was considered suitable for this study. Findings: Five core themes and 24 subthemes were created. These were, (1) Poor health prior to program; (2) Hunger and cravings-the food and mood connection; (3) Psychological well-being improvements; (4) It becomes a lifestyle; and (5) Implementation difficulties. Participants experienced mental health improvements such as increased self-esteem, confidence, motivation, and achievement. Some experienced more control in life and a greater sense of reward. Those with depressive symptoms who initially reported low self-worth and hopelessness later reported increased self-esteem and renewed meaning and purpose in life. The findings from this study reflect the previous reports that the diet implementation can be difficult initially, but soon becomes easy to follow and turns into a lifestyle. Conclusion: In the literature, there are very few qualitative studies that explore the accounts and lived experiences of those following a KD. From the participants' accounts in this study, it appears that the benefits and positive outcomes of this diet outweigh any negative side-effects experienced. This is encouraging for those who are looking for adjunctive therapies to address and improve their depressive symptoms and overall mental health.

Gaining consensus on emotional wellbeing themes and preferences for digital intervention type and content to support the mental health of young people with long-term health conditions: A Delphi study.

BACKGROUND: Young people (YP) with long-term conditions (LTCs) are at greater risk of psychological distress than those without LTCs. Despite this, there is a scarcity of quality digital interventions designed to help improve mental wellbeing in this population. The aim of this study was to determine what YP, parents and health professionals preferred for future interventions. METHODS: Twenty-six YP with asthma, diabetes and/or epilepsy (the three most common LTCs in YP), 23 parents of YP with LTCs and 10 health professionals mainly in paediatric specialisms (total n = 59) took part in an online Delphi study to gain consensus (set at 75% agreement) on four questions across three rounds. Participants ordered psychological themes that may be experienced by YP with LTCs by importance and ranked digital intervention types and delivery modes by importance or usefulness. The most common results were reported if no consensus was reached by round 3. RESULTS: Participants preferred a mobile phone app (73% agreement) and a mixture of one-on-one and group support for an intervention (75% agreement). The two highest ranked psychological themes were anxiety (44%) and wanting to appear 'normal' (38%), and the top intervention type was 'general counselling' (54% agreement). CONCLUSION: There was a clear desire for an app to help with the psychological aspects of living with LTCs and for a combination of one-to-one and group intervention elements. Anxiety and wanting to appear 'normal' might be two closely linked psychological challenges that could be addressed by a single intervention. IMPLICATIONS: The results will be important to consider for a future intervention, although further consultation will be needed for app development. PATIENT OR PUBLIC CONTRIBUTION: Two YP with a LTC provided feedback on the study protocol including the aims and procedures of the project. Another six YP with LTCs were consulted on an early draft of the study questionnaire (the four questions), which was subsequently revised. Once the project began, a patient and public involvement group consisting of two YP with LTCs and one parent of a YP with an LTC gave feedback on the research process, lay report of the results and dissemination plan.

A cognitive behavioural model of the bidirectional relationship between disordered eating and diabetes self care in adult men with Type 1 diabetes mellitus.

AIMS: This qualitative study aimed to develop the first cognitive behavioural (CBT) model outlining the development and maintenance of disordered eating in adult men living with Type 1 diabetes to improve on previous theoretical models of Type 1 diabetes and disordered eating and to draw comparisons to women with Type 1 diabetes and disordered eating. METHODS: Twenty-seven men (n = 16 with Type 1 diabetes and disordered eating, n = 11 with Type 1 diabetes without disordered eating) participated in semi-structured interviews. Data were analysed using thematic analysis and individual CBT formulations were developed for each participant to inform the model. RESULTS: Men with Type 1 diabetes and disordered eating experience negative thoughts about food, insulin, weight/shape and diabetes itself, which cause negative emotions such as fear and vulnerability and difficulties with diabetes self care such as problems with hyper and hypoglycaemia and problems accessing structured education and technology result in men feeling more dissatisfied about their body weight/shape. CONCLUSIONS: This CBT model of disordered eating in men with Type 1 diabetes can guide new interventions.

Protocol for the STEADY intervention for type 1 diabetes and disordered eating: Safe management of people with Type 1 diabetes and EAting Disorders studY.

This paper describes the protocol to test the feasibility of the Safe management of people with Type 1 diabetes and EAting Disorders studY (STEADY) intervention. STEADY is a novel complex intervention for people with type 1 diabetes and disordered eating (T1DE) of mild to moderate severity. The STEADY intervention integrates cognitive behavioural therapy (CBT) with diabetes education, and was developed using Experience-Based Co-Design. METHODS: The feasibility of STEADY will be tested using a randomised controlled feasibility trial. Forty adults with T1DE will be recruited and randomised into the STEADY intervention or treatment as usual control group. We will collect demographic, biomedical and psychometric data, routine glucose metrics and conduct the Structured Clinical Interview for DSM-5. Participants randomised to the STEADY intervention will receive 12 STEADY therapy sessions with a diabetes specialist nurse trained in CBT, delivered via videoconference and an optional smartphone app. The main outcome at 6 months will be the feasibility of STEADY (recruitment, dropout rates, feasibility of delivery). The secondary outcomes are biomedical (HbA1c and glucose time in range) and psychological (person-reported outcome measures in disordered eating, diabetes distress, depression and anxiety). A process evaluation will evaluate the fidelity, feasibility, acceptability and appropriateness of STEADY, and participant experiences. ETHICS AND DISSEMINATION: The protocol was approved by the East of England-Essex Research Ethics Committee (21/EE/0235). Study findings will be shared with study participants and disseminated through peer-reviewed publications and conference presentations.

Developing a novel intervention for type 1 diabetes and disordered eating using a participatory action design process: Safe management of people with Type 1 diabetes and EAting Disorders studY (STEADY).

AIMS: To develop a cognitive behavioural therapy-based intervention for people with type 1 diabetes and disordered eating using Experience-Based Co-Design as part of the Safe management of people with Type 1 diabetes and EAting Disorders studY (STEADY). METHODS: Fifteen people with type 1 diabetes and experience of disordered eating (33 ± 11 years old, 22 ± 12 years diabetes duration) and 25 healthcare professionals working in type 1 diabetes or eating disorders (44 ± 9 years old; 14 ± 10 years of professional experience) attended six Experience-Based Co-Design workshops from July 2019 to March 2020 to collaboratively develop intervention content. RESULTS: We developed a cognitive behaviour therapy intervention 'toolkit' that can be tailored for individual patient needs. Participants designed and revised toolkit materials to ensure acceptability and relevance for people with diabetes and disordered eating by engaging in guided discussion, brainstorming, and rapid testing to review toolkit prototypes in an iterative process. Workshop themes were 'Insulin titration'; 'Hypoglycaemia'; 'Coming to terms with diabetes'; 'Fear of weight gain'; 'Toolkit revision'; and 'Practical elements of STEADY therapy'. The intervention is focussed on improving diabetes self-care and embedded in a multidisciplinary healthcare approach. The intervention will be delivered in 12 sessions by a diabetes specialist nurse trained in cognitive behavioural therapy. CONCLUSIONS: Through an iterative co-design process, people with type 1 diabetes and healthcare professionals collaboratively developed a novel intervention toolkit that can be used with a wide range of disordered eating presentations. The intervention will be tested in the STEADY feasibility randomised controlled trial.

A cognitive behavioural model of the bidirectional relationship between disordered eating and diabetes self care in people with type 1 diabetes mellitus.

AIMS: This qualitative study aimed to develop the first cognitive behavioural therapy model outlining the development and maintenance of disordered eating in type 1 diabetes and report on recovery strategies and resilience factors to improve previous theoretical models of type 1 diabetes and disordered eating. METHODS: Twenty-three women (n = 9 with type 1 diabetes and disordered eating, n = 5 with type 1 diabetes recovering from disordered eating, and n = 9 with type 1 diabetes without disordered eating) participated in semi-structured interviews. Data were analysed using grounded theory and individual cognitive-behavioural formulations were developed for each participant to inform the development/maintenance and resilience models. RESULTS: The development/maintenance model summarises commonly experienced vicious cycles of thoughts, feelings and behaviours in type 1 diabetes and disordered eating. The resilience model summarises strategies and knowledge acquired by those with type 1 diabetes in recovery from disordered eating and individuals with type 1 diabetes who did not develop disordered eating. Early adverse life events, past psychiatric history, perfectionist personality traits, difficult experiences around type 1 diabetes diagnosis and its relentless daily management sensitise individuals to eating, weight and shape cues. Alongside physical symptoms/complications, unhelpful interpersonal reactions and inadequate healthcare, vicious cycles of thoughts, feelings and behaviours develop. 'Good enough' psychological adaptation to type 1 diabetes, integrating type 1 diabetes into one's identity, self care and compassion around eating, weight and shape were key protective/post-traumatic resilience factors. CONCLUSIONS: This first cognitive behavioural therapy model of type 1 diabetes and disordered eating informed by personal experience will inform an intervention for type 1 diabetes and disordered eating.

Feasibility study of real-time online text-based CBT to support self-management for people with type 1 diabetes: the Diabetes On-line Therapy (DOT) Study.

INTRODUCTION: This study examines the feasibility of conducting diabetes-focused cognitive-behavioral therapy (CBT) via a secure online real-time instant messaging system intervention to support self-management and improve glycemic control in people with type 1 diabetes. RESEARCH DESIGN AND METHODS: We used a pre-post uncontrolled intervention design over 12 months. We recruited adults with type 1 diabetes and suboptimal glycemic control (HbA1c ≥69 mmol/mol (DCCT 8.5%) for 12 months) across four hospitals in London. The intervention comprised 10 sessions of diabetes-focused CBT delivered by diabetes specialist nurses. The primary outcomes were number of eligible patients, rates of recruitment and follow-up, number of sessions completed and SD of the main outcome measure, change in HbA1c over 12 months. We measured the feasibility of collecting secondary outcomes, that is, depression measured using Patient Health Questionnaire-9 (PHQ-9), anxiety measured Generalised Anxiety Disorder (GAD) and the Diabetes Distress Scale (DDS). RESULTS: We screened 3177 patients, of whom 638 were potentially eligible, from whom 71 (11.1%) were recruited. The mean age was 28.1 (13.1) years, and the mean HbA1c was 84.6 mmol/mol (17.8), DCCT 9.9%. Forty-six (65%) patients had at least 1 session and 29 (41%) completed all sessions. There was a significant reduction in HbA1c over 12 months (mean difference -6.2 (2.3) mmol/mol, DCCT 0.6%, p=0.038). The change scores in PHQ-9, GAD and DDS also improved. CONCLUSIONS: It would be feasible to conduct a full-scale text-based synchronized real-time diabetes-focused CBT as an efficacy randomized controlled trial.

Healthcare professionals' perspectives on enrolled nurses, practical nurses and other second-level nursing roles: A systematic review and thematic synthesis.

BACKGROUND: Significant workforce shortages and economic pressures have led to the expanded scope and reintroduction of new roles for second-level nurses in many Organization for Economic Co-operation and Development countries. Given this, there is a need to understand the emic and etic perspectives of second-level nurses, to ensure collaborative teamwork and safe patient care. OBJECTIVE: This review aimed to systematically identify, appraise, and synthesize qualitative research evidence on healthcare professionals' perspectives on second-level nursing roles in the healthcare workforce. These findings inform recommendations that would influence the development and implementation of these roles in healthcare organisations. DESIGN: A systematic review and thematic synthesis of qualitative research was conducted. Six databases were systematically searched and forward and backwards searching completed. Included studies focused on healthcare professionals' perspectives (including views of second-level nurses themselves) on second-level nursing roles. All included articles were from Organization for Economic Co-operation and Development countries. The Critical Appraisal Skills Programme checklist for qualitative research was used to assess the evidence quality. The results section of each included article was coded and descriptive themes were developed. An interpretative and iterative process led to the final analytic themes. FINDINGS: Twenty-six qualitative studies were identified from five countries over 26 years. Four analytic themes were identified: undifferentiated role; efficient but limited; subordinated task-doers; and broadening scope and strengthened identity. The synthesis demonstrated dichotomies wherein some second-level nursing roles were devalued, and others had increasing scope and responsibility. Role and boundary confusion was evident and had not decreased over time. Hierarchies in nursing practice underlined the split between critical thinking and hands-on approaches to care which, in some cases, debased the second-level nursing role because of its association with practical hands-on care. CONCLUSIONS: The analytic themes in this synthesis suggest that second-level nurses have faced the same issues over decades with little change. Perceptions of second-level nursing roles are primarily influenced by meso (organisational level) factors and micro (individual, behavioural) factors. The synthesis concludes that a cultural shift in valuing the hands-on care provided by second-level nursing is necessary, along with systems-level shift that clarifies the role of second-level nursing within healthcare teams to enhance collaborative practice. Further research should attend to macro-level influences on perceptions of second-level nurses, the work they do, and how this is valued or institutionally embedded. Tweetable abstract: Healthcare professionals' perspectives on second-level nursing roles: a systematic review and thematic synthesis.

Evolutionary Influences on Attribution and Affect.

Evolutionary theory was applied to Reeder and Brewer's schematic theory and Trafimow's affect theory to extend this area of research with five new predictions involving affect and ability attributions, comparing morality and ability attributions, gender differences, and reaction times for affect and attribution ratings. The design included a 2 (Trait Dimension Type: HR, PR) × 2 (Behavior Type: morality, ability) × 2 (Valence: positive, negative) × 2 (Replication: original, replication) × 2 (Sex: female or male actor) × 2 (Gender: female or male participant) × 2 (Order: attribution portion first, affect portion first) mixed design. All factors were within participants except the order and participant gender. Participants were presented with 32 different scenarios in which an actor engaged in a concrete behavior after which they made attributions and rated their affect in response to the behavior. Reaction times were measured during attribution and affect ratings. In general, the findings from the experiment supported the new predictions. Affect was related to attributions for both morality and ability related behaviors. Morality related behaviors received more extreme attribution and affect ratings than ability related behaviors. Female actors received stronger attribution and affect ratings for diagnostic morality behaviors compared to male actors. Male and female actors received similar attribution and affect ratings for diagnostic ability behaviors. Diagnostic behaviors were associated with lower reaction times than non-diagnostic behaviors. These findings demonstrate the utility of evolutionary theory in creating new hypotheses and empirical findings in the domain of attribution.

Biological and psychological correlates of self-reported and objective sleep measures.

OBJECTIVE: Objective and self-reported sleep are only moderately correlated and it is uncertain if these two types of sleep measures are associated with distinct biological and psychological outcomes. METHODS: Participants were 119 healthy women aged 26years on average. Cortisol and blood pressure assessed over one day were the measures of biological function. Psychological variables included optimism, life satisfaction, positive and negative affect as well as emotional distress. Sleep was assessed with the Pittsburgh Quality Index (PSQI), wrist actigraphy and sleep diaries. RESULTS: Global sleep ratings on the PSQI were unrelated to objective sleep efficiency, duration or latency. Sleep duration derived from sleep diaries was highly correlated with objective duration but was unrelated to the PSQI measure. More disturbed sleep on the PSQI was associated with lower psychological wellbeing, as indicated by reduced levels of optimism, life satisfaction and positive affect as well as greater negative affect and emotional distress. Objective sleep efficiency was reduced among participants with lower positive and higher negative affect but there were no other associations between objective sleep indicators and psychological variables tested in our study. Participants with poorer self-reported sleep had lower cortisol awakening response while those with longer objective sleep latency had higher diastolic blood pressure, independently of covariates. CONCLUSION: Our study reveals that self-reported and objective sleep measures, in particular those regarding sleep quality, are weakly associated but have different psychological and biological correlates. This suggests that findings relating self-reported sleep may not necessarily be corroborated by objective sleep indicators.

The impact of a brief gratitude intervention on subjective well-being, biology and sleep.

This randomised controlled experiment tested whether a brief subjective well-being intervention would have favourable effects on cardiovascular and neuroendocrine function and on sleep. We compared 2 weeks of a gratitude intervention with an active control (everyday events reporting) and no treatment conditions in 119 young women. The treatment elicited increases in hedonic well-being, optimism and sleep quality along with decreases in diastolic blood pressure. Improvements in subjective well-being were correlated with increased sleep quality and reductions in blood pressure, but there were no relationships with cortisol. This brief intervention suggests that subjective well-being may contribute towards lower morbidity and mortality through healthier biological function and restorative health behaviours.

How do people form behavioral intentions when others have the power to determine social consequences?

Much literature has suggested that people who are discriminated against or are in collectivist cultures are particularly susceptible to the social consequences of society. In the present study, the authors conducted 3 experiments to test how this factor influences attitudinal versus normative control over behaviors. First, they measured males' and females' attitudes, subjective norms, and behavioral intentions with respect to a large number of behaviors. Although between-participants analyses were mostly uninformative, within-participants analyses uncovered strong evidence that behaviors are more under attitudinal control for females than for males. Similar analyses in a crosscultural experiment involving participants from the United States, the United Kingdom, China, and Mexico support the hypothesis that behaviors are more under attitudinal control for collectivists than for individualists. Finally, experimental data collected in the United States and Saudi Arabia further support this conclusion. Taken together, the findings suggest that although social consequences are both "social" and "consequences", the latter is more important than the former.

Acute effects of alcohol on memory: impact of emotional context and serial position.

Although the amnestic effects of alcohol in humans are well known, its effects on emotional memory are unclear. In this study, using a randomized double-blind placebo-controlled design, we examine narrative emotional episodic memory in healthy human female volunteers (n=32) who received either a single dose of alcohol (0.6g/kg), or a placebo and then viewed neutral story elements presented in either a neutral or emotional context. Memory was tested for gist and detail of the neutral elements 3days later in a surprise recognition test. Since alcohol modulates GABAergic neurotransmission and may exert its effects on emotion through the limbic system, we predicted that acute alcohol treatment would reduce the expected emotional memory-advantage for gist, leaving detail memory relatively unaffected. Furthermore, given previous findings showing that 'primacy' memory is enhanced by physiological arousal, we predicted that reduced arousal produced by alcohol would have the opposite effect and impair primacy memory relative to the middle or 'recency' sections of the narrative. Emotional arousal was expected to oppose this effect, so impaired primacy memory following alcohol was only expected in the neutral version of the narrative. Although there was a main effect of story phase (though not of story version), contrary to expectations, alcohol impaired primacy memory for emotionally encoded neutral material. The results suggest that under certain circumstances emotional context or physiological arousal make memories labile and susceptible to disruption through pharmacological manipulation during encoding.

The generality of negative hierarchically restrictive behaviours.

Previous research has shown that when an actor engages in a negative hierarchically restrictive behaviour, a strong correspondent trait attribution is made and this behaviour is expected to generalize across situations (Trafimow, 2001). This paper discusses three experiments that examined the effects of extreme situations and perceived morality of the actor on the way in which participants make trait attributions, and the extent to which those behaviours are expected to generalize to other situations. Findings from Experiments 1 and 2 indicate that even negative hierarchically restrictive behaviours do not always lead to strong correspondent inferences if the situation in which the initial behaviour was performed was sufficiently extreme. Experiment 3 served to support these findings and cleared up questions from the first two experiments. Findings supported the hypothesis that some situations inhibit negative trait attributions and behaviour generalizations. Furthermore, findings indicate that the perception of the morality of the actor determines whether or not a negative hierarchically restrictive behaviour will lead to a negative trait attribution and generalization.

Affective and cognitive control of persons and behaviours.

Three studies assessed the relative contribution of affect and cognition to determining behavioural intentions for a variety of behaviours using both between-participants and within-participants analyses. The between-participants analyses showed that affect tends to make more of a contribution than does cognition for more behaviours. However, the within-participants analyses indicated that there are strong individual differences among people. Some people are more under affective control, across behaviours, whereas other people are more under cognitive control. The most interesting finding was that, despite the potential independence of between-participants and within-participants analyses (Mischela, 1990), between-participants analyses on subsamples created from the within-participants analyses showed significant dependence. The predictive validity of affect vs. cognition depended upon whether participants were affectively or cognitively controlled.

Generalization of the negativity effect to self-attributions.

In 1979 Reeder and Brewer reported that people make stronger attributions for negative behaviors than for positive ones, following Hastorf and Cantril's statement that people are motivated to maintain positive self-views. The present study tested whether 67 participants would make stronger self-attributions for negative behaviors than for positive ones by having them indicate the number of times that they had to engage in a specific behavior before it would become a trait they possess. Analysis confirmed that participants make stronger self-attributions for negative behaviors than for positive behaviors.

The relative influence of attitudes and subjective norms from childhood to adolescence: between-participant and within-participant analyses.

Children and adolescents (ages 8-16) were asked to indicate their behavioral intentions, attitudes, and subjective norms for 34 behaviors. Between-participant and within-participant analyses demonstrated that attitudes and subjective norms were good predictors of behavioral intentions both singly and in combination. In addition, attitudes generally were better predictors than were subjective norms both across behaviors and across participants. Most importantly, however, there were no differences in the relative importance of attitudes and subjective norms in predicting behavioral intentions across age groups.

The father-daughter relationship rating scale.

A 9-item scale designed to measure perceived relationships of girls and their fathers is internally consistent (alpha=.89) and showed clear factor structure.