An exploratory randomized controlled study of a healthy living intervention in early intervention services for psychosis: the INTERvention to encourage ACTivity, improve diet, and reduce weight gain (INTERACT) study.

BACKGROUND: People with psychosis often experience weight gain, which places them at risk of cardiovascular disease, diabetes, and early death. OBJECTIVE: To determine the uptake, adherence, and clinical effectiveness of a healthy living intervention designed to reduce weight gain. METHOD: An exploratory randomized controlled trial, comparing the intervention with treatment as usual (TAU) in 2 early intervention services for psychosis in England. DSM-IV classification was the diagnostic criteria used to assign the psychiatric diagnoses. The primary outcome was change in body mass index (BMI) from baseline to 12-month follow-up. The study was conducted between February 2009 and October 2012. RESULTS: 105 service users, with a BMI of ≥ 25 (≥ 24 in South Asians), were randomized to intervention (n = 54) or TAU (n = 51) after stratification by recent commencement of antipsychotic medication. Ninety-three service users (89%) were followed up at 12 months. Between-group difference in change in BMI was not significant (effect size = 0.11). The effect of the intervention was larger (effect size = 0.54, not significant) in 15 intervention (28%) and 10 TAU (20%) participants who were taking olanzapine or clozapine at randomization. CONCLUSIONS: The healthy living intervention did not show a significant difference in BMI reduction compared to the TAU group. TRIAL REGISTRATION: www.isrctn.org identifier: ISRCTN22581937.

Case management for high-intensity service users: towards a relational approach to care co-ordination.

This study is based on a formative evaluation of a case management service for high-intensity service users in Northern England. The evaluation had three main purposes: (i) to assess the quality of the organisational infrastructure; (ii) to obtain a better understanding of the key influences that played a role in shaping the development of the service; and (iii) to identify potential changes in practice that may help to improve the quality of service provision. The evaluation was informed by Gittell's relational co-ordination theory, which focuses upon cross-boundary working practices that facilitate task integration. The Assessment of Chronic Illness Care Survey was used to assess the organisational infrastructure and qualitative interviews with front line staff were conducted to explore the key influences that shaped the development of the service. A high level of strategic commitment and political support for integrated working was identified. However, the quality of care co-ordination was variable. The most prominent operational factor that appeared to influence the scope and quality of care co-ordination was the pattern of interaction between the case managers and their co-workers. The co-ordination of patient care was much more effective in integrated co-ordination networks. Key features included clearly defined, task focussed, relational workspaces with interactive forums where case managers could engage with co-workers in discussions about the management of interdependent care activities. In dispersed co-ordination networks with fewer relational workspaces, the case managers struggled to work as effectively. The evaluation concluded that the creation of flexible and efficient task focused relational workspaces that are systemically managed and adequately resourced could help to improve the quality of care co-ordination, particularly in dispersed networks.

What work has to be done to implement collaborative care for depression? Process evaluation of a trial utilizing the Normalization Process Model.

BACKGROUND: There is a considerable evidence base for 'collaborative care' as a method to improve quality of care for depression, but an acknowledged gap between efficacy and implementation. This study utilises the Normalisation Process Model (NPM) to inform the process of implementation of collaborative care in both a future full-scale trial, and the wider health economy. METHODS: Application of the NPM to qualitative data collected in both focus groups and one-to-one interviews before and after an exploratory randomised controlled trial of a collaborative model of care for depression. RESULTS: Findings are presented as they relate to the four factors of the NPM (interactional workability, relational integration, skill-set workability, and contextual integration) and a number of necessary tasks are identified. Using the model, it was possible to observe that predictions about necessary work to implement collaborative care that could be made from analysis of the pre-trial data relating to the four different factors of the NPM were indeed borne out in the post-trial data. However, additional insights were gained from the post-trial interview participants who, unlike those interviewed before the trial, had direct experience of a novel intervention. The professional freedom enjoyed by more senior mental health workers may work both for and against normalisation of collaborative care as those who wish to adopt new ways of working have the freedom to change their practice but are not obliged to do so. CONCLUSIONS: The NPM provides a useful structure for both guiding and analysing the process by which an intervention is optimized for testing in a larger scale trial or for subsequent full-scale implementation.

Is chronic pelvic pain a comfortable diagnosis for primary care practitioners: a qualitative study.

BACKGROUND: Chronic pelvic pain (CPP) has a prevalence similar to asthma and chronic back pain, but little is known about how general practitioners (GPs) and practice nurses manage women with this problem. A clearer understanding of current management is necessary to develop appropriate strategies, in keeping with current health care policy, for the supported self-management of patients with long term conditions. The aim of this study was to explore GPs' and practice nurses' understanding and perspectives on the management of chronic pelvic pain. METHODS: Data were collected using semi-structured interviews with a purposive sample of 21 GPs and 20 practice nurses, in three primary care trusts in the North West of England. Data were analysed using the principles of Framework analysis. RESULTS: Analysis suggests that women who present with CPP pose a challenge to GPs and practice nurses. CPP is not necessarily recognized as a diagnostic label and making the diagnosis was achieved only by exclusion. This contrasts with the relative acceptability of labels such as irritable bowel syndrome (IBS). GPs expressed elements of therapeutic nihilism about the condition. Despite practice nurses taking on increasing responsibilities for the management of patients with long term conditions, respondents did not feel that CPP was an area that they were comfortable in managing. CONCLUSIONS: The study demonstrates an educational/training need for both GPs and practice nurses. GPs described a number of skills and clinical competencies which could be harnessed to develop a more targeted management strategy. There is potential to develop facilitated self- management for use in this patient group, given that this approach has been successful in patients with similar conditions such as IBS.

Preparation for pain management during childbirth: the psychological aspects of coping strategy development in antenatal education.

During childbirth, in addition to or in place of analgesia, women manage pain using a range of coping strategies. Antenatal education provides an opportunity prior to birth to help women to prepare for an often painful event. However, this is usually carried out with little reference to the literature regarding psychological factors which influence the experience of pain. This review seeks to consider how recent developments in psychological knowledge could enhance care. Areas identified include range of coping strategies and factors influencing their efficacy and implementation. This draws on both the literature on management of acute pain in other scenarios and the limited literature related to childbirth related pain. The following recommendations for systematic evaluation in the context of antenatal education are made: (i) Increase the range of coping strategies currently utilized to include cognitive based strategies. (ii) Help women to identify and understand the nature of their own coping styles and preferences, including any unhelpful patterns of pain catastrophizing. (iii) Help women to develop their own unique set of coping strategies for labor. (iv) Strengthen feelings of coping self-efficacy by practice in class and reinforcement by the class teacher. (v) Develop implementation intentions which account for the changing context of childbirth and (vi) Actively develop prompting and reinforcement of use of identified coping strategies by birth partners.

Patients' experiences of receiving collaborative care for the treatment of depression in the UK: a qualitative investigation.

Objective We explored the experiences of patients who received treatment for depression during a 'phase II' platform trial of collaborative care in the UK.Method Semi-structured interviews were used to obtain information from 13 patients receiving collaborative care. Patients from a range of general practitioner (GP) practices within the trial were purposively sampled. The constant comparative approach within a framework analysis was used to identify emerging concepts and key themes.Results Three distinct themes in people's experience of collaborative care were identified: (1) the process of collaborative care; (2) the content of collaborative care; and (3) staying well. These themes were set against a backdrop in which patients described how they had been struggling with lowmood. Our central therapeutic ingredients of information giving, behavioural activation and medication management were supported by patients. Patients expressed reservations about the rigid inflexibility of telephone-based treatment.Conclusions While most of the protocol elements were supported by patients, we have been able to amend our protocol to allow for greater delivery flexibility and more attention to the therapeutic alliance and relapse prevention. We are now testing this in a multicentre randomised controlled trial.

Preliminary evaluation of a coping strategy enhancement method of preparation for labour.

OBJECTIVES: To compare the use and effects of enhanced pre-existing coping strategies with the use and effects of coping strategies usually taught in National Health Service (NHS) antenatal education on women's experience of pain and emotions during labour. DESIGN: A between-group comparison of women who chose to attend NHS antenatal education where courses of preparation were randomly assigned to include either a new method of coping strategy enhancement (CSE) or standard taught coping strategies. SETTING: Two large maternity units in one city in the North of England. PARTICIPANTS: 20 women participated in antenatal classes incorporating the CSE method and 21 women participated in antenatal classes incorporating the standard approach to developing coping strategies for labour. FINDINGS: Women who attended CSE classes used enhanced coping strategies for a larger proportion of their labour than women who attended standard classes who used taught coping strategies. Birth companions were more involved in women's use of enhanced than taught strategies. Self-efficacy for use of coping strategies and subsequent experiences of pain and emotions during labour were equivalent between groups. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: An approach based on enhancing pre-existing coping strategies was associated with greater coping strategy use and involvement from the birth companion, and provided benefits to women's overall experience of labour at least equivalent to that associated with standard preparation. Further research should explore this novel approach in larger groups, and for women who may choose not to attend group antenatal preparation.

The range of coping strategies women use to manage pain and anxiety prior to and during first experience of labour.

OBJECTIVES: To investigate whether nulliparous women, during pregnancy, can identify their own pre-existing coping strategies for managing pain and anxiety and whether the range of coping strategies used in Labour by women who do not attend antenatal classes can be described. DESIGN: Qualitative semi-structured interviews. SETTING: Two large maternity units in a city in the North of England. PARTICIPANTS: Twenty-three nulliparous women were interviewed during their third trimester of pregnancy (prior to any antenatal class attendance) regarding strategies used to cope with previous experiences of pain and anxiety. A separate sample of 20 women, who had not attended any form of antenatal education, were interviewed within 72h of their first experience of labour regarding the coping strategies used to manage pain and anxiety during labour. FINDINGS: Template Analysis was used to code data from transcribed interviews. The findings indicate that as women approach their first experience of labour they can identify coping strategies that they have employed to manage pain and anxiety in their past. Equally women who have not attended antenatal classes use a wide range of strategies in labour. The range of identified coping strategies is described and comprises thoughts and behaviours with positive and negative consequences. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: It is possible to help nulliparous women to identify, in pregnancy, a range of strategies that they have previously employed to manage pain and anxiety. This range reflects the coping strategies that women may potentially use in labour to manage pain and anxiety. Women may benefit from assistance in pregnancy to develop strategies for labour that are based on knowledge of their own coping repertoire, which includes enhancing positive strategies and finding alternatives to negative strategies.

Selected coping strategies in labor: an investigation of women's experiences.

BACKGROUND: Antenatal education classes offer women information about labor and birth and ways of coping with pain and emotional distress. The purpose of this paper was to describe women's experiences of using, starting, and discontinuing three coping strategies in labor that were taught in antenatal education classes. METHODS: An exploratory research design was used in which 121 women were interviewed within 72 hours of the birth of their first child. Information was obtained on why women initiated and discontinued their use of three coping strategies (breathing technique, postural changes, relaxation technique) and the reported effects of use. RESULTS: The effects of the coping strategies investigated varied widely among participants. Common aspects of care, changes of environment, and use of pharmacological pain relief affected women's discontinuation of coping strategies. CONCLUSIONS: The implications of study findings for clinical practice include the need for caregivers to provide women with accurate information about the effects of coping strategies and to be alert to aspects of care that may disrupt women's use of strategies.