Factors to consider during the implementation of nutrition and physical activity trials for people with psychotic illness into an Australian community setting.

BACKGROUND: Research in lifestyle interventions focusing on nutrition and physical activity in people living with psychotic illness, highlights anthropometric and metabolic benefits of these interventions. However, little is known about potential factors to consider during implementation into real-world contexts. Community-managed organisations (CMOs) that provide services for people with mental illness, offer an ideal implementation context for lifestyle interventions. Successful translation of lifestyle interventions into CMOs may be achieved though considering the factors associated with program access and delivery in these settings. This study primarily aimed to identify the factors that affect program access in a local CMO from the perspective of consumers and staff. The secondary aim was to describe the elements that impact on program delivery from the perspective of staff. METHODS: Thirteen semi-structured interviews were conducted with 6 consumers and 7 staff in a CMO in regional Australia. Topics explored in interviews were based on implementation concepts identified in the "Integrated Promoting Action on Research Implementation in Health Systems" (i-PARIHS) knowledge translation framework. Thematic data analysis was conducted using Nvivo software. RESULTS: Emergent themes on issues that influenced program access were (1) consumer financial status, domestic responsibilities, and health; (2) the design and delivery of programs; (3) structure and practices of the organisation; (4) attitude, skills and effort of staff involved in program delivery; and (5) social connections and stigma experienced by consumers during program access. Moreover, staff perceptions on elements that impacted program delivery highlighted themes on consumer attendance and interest in prospective programs, availability and restrictions to the use of funding, as well as the organisational structure and practices. CONCLUSIONS: The factors affecting program access and delivery can generally be managed or planned for during the design of lifestyle interventions and subsequent translation into the CMO context. However, resolution of issues related to consumer financial status and health requires the collaboration of various government sectors for system-wide solutions.

An appraisal of methodology reporting in lifestyle interventions among people with psychosis: A systematic review.

ISSUE ADDRESSED: Lifestyle interventions use nutrition and physical activity behaviour modification techniques to decrease obesity and cardio-metabolic risk in people with psychosis. Evidence on the specific behaviour modification strategies applied to decrease obesity is weakened by inadequate methodology reporting of lifestyle interventions. A systematic review that we conducted earlier highlighted a possible deficiency in reporting; hence we aim to critically appraise lifestyle intervention studies that target weight outcomes for people with psychosis against the methods component of the CONSORT statement for randomised trials of nonpharmacologic treatments. METHODS COMPONENT: We considered randomised controlled studies which delivered lifestyle interventions to community-dwelling adults with psychotic disorders, and included those with the following outcomes of interest: weight, body mass index, waist circumference and waist-to-hip ratio. The Cochrane Library, MEDLINE/PREMEDLINE, EMBASE, CINAHL, Scopus and PsycINFO were searched for English publications between 1985 and 2018. Methodology and reporting of studies were evaluated using the CONSORT statement for randomised trials of nonpharmacologic treatments. RESULTS: Thirty-two studies met the inclusion criteria. Critical appraisals revealed that reporting of lifestyle intervention studies was generally incomplete. Fewer than 50% provided the recommended information on trial design, participant characteristics, detail of interventions, outcomes, sample size, randomisation, blinding and statistical methods. CONCLUSIONS: Application of guidelines, like the CONSORT statement, in future publications of lifestyle interventions for people with psychosis will improve accuracy of reporting. SO WHAT?: Enhanced reporting in lifestyle intervention studies for people with psychosis will promote guideline creation and translation of research, which is likely to positively impact physical health outcomes.

Comparative efficacy of lifestyle intervention strategies targeting weight outcomes in people with psychosis: a systematic review and network meta-analysis.

OBJECTIVES: The objective of this review was to pool and rank the efficacy of lifestyle intervention strategies targeting weight, body mass index, waist circumference and waist-to-hip ratio in people with psychosis by comparing the effect size of these weight outcomes. Secondary to this, the objective was to stratify the lifestyle interventions according to their inclusion of dietary information that adheres to Australian Dietary Guidelines. INTRODUCTION: People living with psychosis have a significantly increased risk of all-cause mortality, with cardiovascular disease a considerable contributor to this risk. Controlling lifestyle risk factors, which include smoking, poor diet and inadequate physical activity, leads to significant weight reduction and decreases cardiovascular disease risk. Previous reviews on this topic have not clearly identified essential components of lifestyle interventions in people with psychosis, mainly due to statistical limitations of analyses. This review employed a network meta-analysis, which compares more than two groups of interventions and ranks them according to efficacy, thus providing a global estimate of effect. Additionally, available reviews have not assessed compliance of dietary information offered in lifestyle interventions to established guidelines. INCLUSION CRITERIA: This review considered randomized controlled trials that delivered lifestyle interventions to community-dwelling adults with psychotic disorders. Outcomes of interest included weight, body mass index, waist circumference and waist-to-hip ratio. METHODS: The Cochrane Library, MEDLINE/PreMEDLINE, Embase, CINAHL, Scopus and PsycINFO were searched for studies published in English from 1985 to June 2018. Data were qualitatively summarized, during which lifestyle intervention subgroups were created (based on key similarities) and then compared in direct meta-analyses and network meta-analyses. Assessment of study adherence to Australian Dietary Guidelines was conducted in a narrative format. RESULTS: Thirty-two randomized controlled trials were included, and the overall quality of these studies ranged from what appeared to be low to moderate. Lifestyle intervention studies contained both a dietary and physical activity component, with the exception of two studies that focused solely on physical activity. Delivery of dietary and physical activity information was mainly through education; however, some studies provided additional structure to the intervention by offering tailored advice or helping participants to set goals, and providing regular review of progress for diet, physical activity or both. Results from network-meta-analyses showed that only studies with a structured approach for both diet and physical activity demonstrated significant decreases in weight (effect size = -4.12, 95% confidence interval = -7.772 to -2.760, P = 0.000) and body mass index (effect size = -2.94, 95% confidence interval = -1.78 to -0.357, P = 0.003). Waist circumference subgroup comparisons mainly comprised single studies; therefore, findings were inconclusive. Dietary information provided in studies generally complied with Australian Dietary Guidelines; however, none of the studies complied with all guidelines. CONCLUSIONS: Lifestyle interventions incorporating both dietary and physical activity components led to the greatest decreases in weight (4.1 kg) and body mass index (2.9 points) among people with psychosis. Important intervention strategies for both components are the personalization of education through tailored advice or goal setting, and a corresponding progress review. Dietary information in the included studies appeared to comply with the Australian Dietary Guidelines. However, these findings were weakened by an increased risk of bias, complex and multicomponent study designs, and lack of clarity in reporting of study methodology.

Cardiovascular disease lifestyle risk factors in people with psychosis: a cross-sectional study.

BACKGROUND: People with psychosis die on average 25 years earlier than those in the general population, with cardiovascular disease (CVD) contributing to much of the excess mortality. This cross-sectional study aimed to identify the relationship between lifestyle risk factors for CVD - poor nutrition, smoking and low physical activity levels - and dyslipidaemia, hypertension and hyperglycaemia while controlling for potential confounders in 1825 people from the Survey of High Impact Psychosis (SHIP) in Australia. We also aimed to identify clustering patterns of lifestyle risk factors and associated demographic variables. METHODS: Three logistic regressions were used to predict the effect of nutrition, smoking and physical activity on dyslipidaemia, hypertension and hyperglycaemia while controlling for clozapine use, sex and age. Clustering patterns of nutrition, smoking and physical activity were examined using the two-step cluster method which is based on hierarchical cluster analysis. Demographic variables associated with different clusters were identified using measures of association. RESULTS: Smoking status had a positive association with dyslipidaemia (adjusted odds ratio = 0.50; 95% confidence interval = 0.32-0.78; p = 0.002). Other cardiovascular disease lifestyle risk factors did not have a significant relationship with dyslipidaemia, hypertension and hyperglycaemia. Clustering patterns of lifestyle risk factors showed that younger men, with low education levels, and relying on a government pension, were most likely to display the poorest lifestyle risk behaviours. The largest cluster (42%) of participants was characterised by a mixed demographic profile and were most likely to display poor nutrition and low physical activity levels but less likely to smoke. CONCLUSIONS: Only smoking status had a significant positive association with dyslipidaemia which could indicate that there are additional factors affecting the relationship between other cardiovascular lifestyle risk factors and dyslipidaemia, hypertension and hyperglycaemia in people with psychosis. Unknown confounders and traditional lifestyle risk factors may explain the high rates of CVD in this group. Clustering of lifestyle risk factors and their demographic profiles could help the design of intervention programs in people with psychosis.

Severity of illness and adaptive functioning predict quality of care of children among parents with psychosis: A confirmatory factor analysis.

OBJECTIVE: Parenthood is central to the personal and social identity of many people. For individuals with psychotic disorders, parenthood is often associated with formidable challenges. We aimed to identify predictors of adequate parenting among parents with psychotic disorders. METHODS: Data pertaining to 234 parents with psychotic disorders living with dependent children were extracted from a population-based prevalence study, the 2010 second Australian national survey of psychosis, and analysed using confirmatory factor analysis. Parenting outcome was defined as quality of care of children, based on participant report and interviewer enquiry/exploration, and included level of participation, interest and competence in childcare during the last 12 months. RESULTS: Five hypothesis-driven latent variables were constructed and labelled psychosocial support, illness severity, substance abuse/dependence, adaptive functioning and parenting role. Importantly, 75% of participants were not identified to have any dysfunction in the quality of care provided to their child(ren). Severity of illness and adaptive functioning were reliably associated with quality of childcare. Psychosocial support, substance abuse/dependence and parenting role had an indirect relationship to the outcome variable via their association with either severity of illness and/or adaptive functioning. CONCLUSION: The majority of parents in the current sample provided adequate parenting. However, greater symptom severity and poorer adaptive functioning ultimately leave parents with significant difficulties and in need of assistance to manage their parenting obligations. As symptoms and functioning can change episodically for people with psychotic illness, provision of targeted and flexible support that can deliver temporary assistance during times of need is necessary. This would maximise the quality of care provided to vulnerable children, with potential long-term benefits.

Fostering a culture of research within a clinical radiation oncology department.

INTRODUCTION: Support and investment in increasing a research-active culture in clinical practice needs to be translated at the department and hospital levels as well as regional, state and national levels. We aimed to improve the research culture of our department, to enable more clinical staff to become more research competent and research active. METHODS: We describe and discuss the appointment of a Director of Research and a Research Coordinator into our already-research-active department and the interactions at the research-clinical interface. By identifying barriers and instituting enablers which ameliorate their effect, we explore how a clinical department can utilize the resources already available with the goal of developing a more confident and competent clinician-researcher culture as measured by a range of research metrics. RESULTS: We observed an improved research culture within our department. Our department's improved research culture was reflected by increased numbers of peer-reviewed publications (of 30%), research students/supervisions (of 60%) and engagement of external speakers. We also observed double the number of first-authored peer-reviewed articles and a growth in conference presentations, posters and speaker invitations/awards. In the majority of the research performance metrics tracked, there was a steady improvement noted over the four years monitored. CONCLUSIONS: By responding to the barriers of staff (such as time, expertise and ideas) with structural and personal enablers, as well as funded resources, it is possible to develop research capacity and confidence in a clinical setting.

Rectal protection in prostate stereotactic radiotherapy: a retrospective exploratory analysis of two rectal displacement devices.

INTRODUCTION: High rectal doses are associated with increased toxicity. A rectal displacement device (RDD) reduces rectal dose in prostate stereotactic body radiation therapy (SBRT). This study investigates any dosimetric difference between two methods of rectal displacement (Rectafix and SpaceOAR) for prostate SBRT. METHODS: Rectal dosimetry of 45 men who received SBRT within the PROMETHEUS trial was retrospectively examined, across two radiation therapy centres using the two RDD's. Men received a total dose (TD) of 19 or 20 Gy in two fractions followed by 46 Gy in 23 fractions. Centre 1 contributed 16 Rectafix and 10 SpaceOAR patients. Centre 2 contributed 19 Rectafix patients. Rectal dose volume histogram (DVH) data were recorded as a TD percentage at the following volume intervals; V1%, V2%, V5%, V10% and then 10% increments to V80%. As only one centre employed both RDD's, three sequential rectal dosimetry comparisons were performed; (1) centre 1 Rectafix versus centre 1 SpaceOAR; (2) centre 1 Rectafix versus centre 2 Rectafix and (3) centre 1+ centre 2 Rectafix versus centre 1 SpaceOAR. RESULTS: In comparison (1) Rectafix demonstrated lower mean doses at 9 out of 11 measured intervals (P = 0.0012). Comparison (2) demonstrated a moderate difference with centre 2 plans producing slightly lower rectal doses (P = 0.013). Comparison (3) further demonstrated that Rectafix returned lower mean doses than SpaceOAR (P < 0.001). Although all dose levels were in favour of Rectafix, in absolute terms differences were small (2.6-9.0%). CONCLUSIONS: In well-selected prostate SBRT patients, Rectafix and SpaceOAR RDD's provide approximately equivalent rectal sparing.

Comparative efficacy of lifestyle intervention strategies on weight outcomes in people with psychosis: a systematic review and network meta-analysis protocol.

REVIEW QUESTION/OBJECTIVE:: (i) To systematically review and rank the efficacy of different types of lifestyle intervention strategies on weight outcomes (weight, body mass index [BMI], waist circumference and waist-to-hip ratio) in people with psychosis. (The efficacy of different types of lifestyle intervention strategies will be ranked by comparing the effect size on weight outcomes in people with psychotic disorders.) (ii) To stratify lifestyle interventions that target weight outcomes (weight, BMI, waist circumference and waist-to-hip ratio) in people with psychosis, according to their inclusion of dietary information that adheres with Australian Dietary Guidelines (National Health and Medical Research Council. Eat for Health, Australian Dietary Guidelines Canberra National Health and Medical Research Council; 2013).Specifically, the review question is: What lifestyle intervention strategies targeting weight outcomes (weight, BMI, waist circumference and waist-to-hip ratio) in people with psychosis compared to no treatment or various control conditions have the best efficacy?

Men and women with psychosis and the impact of illness-duration on sex-differences: The second Australian national survey of psychosis.

We aimed to examine and compare sex-differences in people receiving treatment for psychotic illnesses in community settings, based on long or short duration of illness; expecting association between longer illness-duration and worse outcomes in women and men. Clinical, demographic and service-use data from the Survey of High Impact Psychosis were analysed by sex and duration of illness (≤5 years; ≥6 years), using independent t-tests, chi-square tests, one-way ANOVA, and Cramer's V. Of the 1825 participants, 47% had schizophrenia, 17.5% bipolar and 16.1% schizo-affective disorders. More women than men had undertaken post-school education, maintained relationships, and been living in their own homes. Women with a shorter-illness-duration showed social functioning equivalent to non-ill women in the general population. Men tended to have an early illness onset, show premorbid dysfunction, be single, show severe disability, and to use illicit substances. Men with a longer-illness-duration were very socially disadvantaged and isolated, often experiencing homelessness and substance use. Men with a short-illness-duration were most likely to be in paid employment, but two-thirds earned less than $AUD500 per fortnight. Men with longer-illness-duration showed most disability, socially and globally. Interventions should be guided by diagnosis, but also by a person's sex and duration of illness.

Social Dysfunction and Diet Outcomes in People with Psychosis.

This analysis aimed to examine the association of social dysfunction with food security status, fruit intake, vegetable intake, meal frequency and breakfast consumption in people with psychosis from the Hunter New England (HNE) catchment site of the Survey of High Impact Psychosis (SHIP). Social dysfunction and dietary information were collected using standardised tools. Independent binary logistic regressions were used to examine the association between social dysfunction and food security status, fruit intake, vegetable intake, meal frequency and breakfast consumption. Although social dysfunction did not have a statistically significant association with most diet variables, participants with obvious to severe social dysfunction were 0.872 (95% CI (0.778, 0.976)) less likely to eat breakfast than those with no social dysfunction p < 0.05. Participants with social dysfunction were therefore, 13% less likely to have breakfast. This paper highlights high rates of social dysfunction, significant food insecurity, and intakes of fruits and vegetables below recommendations in people with psychosis. In light of this, a greater focus needs to be given to dietary behaviours and social dysfunction in lifestyle interventions delivered to people with psychosis. Well-designed observational research is also needed to further examine the relationship between social dysfunction and dietary behaviour in people with psychosis.

Parents with serious mental illness: differences in internalised and externalised mental illness stigma and gender stigma between mothers and fathers.

Research demonstrates that people living with serious mental illness (SMI) contend with widespread public stigma; however, little is known about the specific experiences of stigma that mothers, and in particular fathers, with SMI encounter as parents. This study aimed to explore and compare the experiences of stigma for mothers and fathers with SMI inferred not only by living with a mental illness but also potential compounding gender effects, and the associated impact of stigma on parenting. Telephone surveys were conducted with 93 participants with SMI who previously identified as parents in the Second Australian National Survey of Psychosis. Results indicated that mothers were more likely than fathers to perceive and internalise stigma associated with their mental illness. Conversely, fathers were more inclined to perceive stigma relating to their gender and to hold stigmatising attitudes towards others. Mental illness and gender stigma predicted poorer self-reported parenting experiences for both mothers and fathers. These findings may assist in tailoring interventions for mothers and fathers with SMI.

The experiences of Australian parents with psychosis: the second Australian National Survey of Psychosis.

OBJECTIVE: Being a parent is an important part of one's identity and role. Previous research outlines many challenges associated with parenting by people with severe mental illness. However, there is a limited research describing parenting experiences of mothers and fathers who have psychosis. METHOD: The second Australian national survey of psychosis recruited 1825 people living with symptoms of, or a diagnosis of, psychosis. The survey was conducted through face-to-face interviews and included key clinical and demographic information, as well as parenting specific information. RESULTS: Over half of all women and a quarter of men were parents. Almost a quarter of women but only 5.5% of the men had dependent children (own and/or stepchildren) living at home with them. Of parents with dependent children, the most common diagnosis was schizophrenia (48.2% fathers, 28.9% mothers), and there were high rates of comorbidity with substance abuse/dependence (alcohol: fathers 69.2%, mothers 44.3%; cannabis: fathers 69.22%, mothers 47.8%). A substantial proportion of parents with dependent children experienced challenges including low educational attainment, unemployment, poverty, and social isolation. Although many parents living with dependent children functioned in the average range, a significant proportion was moderately to severely disabled on global independent functioning ratings (fathers 49.1%, mothers 35.7%) and some were identified as having obvious/severe impairments in their ability to care for their child(ren) (fathers 28.3%, mothers 21.3%). CONCLUSIONS: Most parents living with psychosis function well. However, a significant proportion has impairments in parenting and general functioning that could have adverse consequences for both the parent and children. This study brings into focus the need for interventions to optimise successful parenting outcomes.

Understanding the social costs of psychosis: the experience of adults affected by psychosis identified within the second Australian National Survey of Psychosis.

BACKGROUND: Social inclusion is a key priority of the Fourth National Mental Health Plan for Australia (2009-2014), with strong evidence for its protective impact on mental health. Social integration has been associated with enhanced well-being for people with mental illnesses such as psychosis. OBJECTIVE: To explore the impact of psychosis on an individual's social and community participation. METHOD: The second Australian national survey of psychosis was conducted across seven Australian sites. Semi-structured interviews with adults living with psychosis assessed mental health status, social and role functioning, life satisfaction and future goals. The cohort comprised 1825 adults with a psychotic illness (59.6% were male; 42.4% were aged 18-34 years; 31.5% had 12 years or more of education) of whom 32.7% had been employed in the past year. RESULTS: Most adults indicated experiencing loneliness (80.1%) and a need for more friends (48.1%). Men were more likely to have never had a long-term relationship (59.4% M, 33.2% F). Even though women were more likely to experience anxiety in social situations [(χ(2)(1) = 8.95, p < 0.01)], they were more likely to have attended a social activity in the past year [χ(2)(2) = 11.84, p < 0.01]. Just over half of the survey participants (56.7%) reported having daily or nearly daily contact with family members. In the past year, 69% had not attended any social activity and 43% described stigma as a barrier. Although 63.2% showed significant impairment in social functioning, only 29.5% had received help for this in the last year. Social isolation and loneliness were rated as major challenges by 37.2% of the cohort. CONCLUSIONS: Social isolation and dysfunction experienced by people with psychosis have not decreased since the last Australian national survey of people with psychosis. Alongside education and employment, social functioning and participation must be addressed to improve social inclusion for people with psychosis. Programs targeting social opportunities (befriending, peer support), social anxiety and social functioning for all stages of psychosis are warranted.

Intact sensorimotor gating in adult attention deficit hyperactivity disorder.

Disrupted sensorimotor gating has been found in various neuropsychiatric conditions which are characterized by impaired attention, poor impulse control, dysfunctional dopamine neurotransmission, and neurodevelopmental deficits. We investigated sensorimotor gating by prepulse inhibition (PPI) of the acoustic startle eyeblink reflex in 23 young adults diagnosed with attention deficit hyperactivity disorder (ADHD) as children and still symptomatic at the time of testing and 29 age-matched healthy control subjects. Sensorimotor gating was assessed in a passive listening task at prepulse-to-startle probe intervals of 30, 60, 120, 240, and 480 ms, and subsequently at prepulse-to-startle probe intervals of 60, 120, 240, and 480 ms whilst participants were performing a two-tone auditory discrimination task on the prepulse. Consistent with increased neural maturity and partially remitted symptomatology, our results indicate intact sensorimotor gating for both tasks in adult ADHD with no comorbidity, independent of the subjects' gender and whether ADHD subjects were receiving ongoing stimulant treatment or not. Reduced PPI at 120-ms lead intervals, on the other hand, was recorded in a subset of 10 ADHD subjects who were taken off their prescribed regular stimulants for 24 h and tested in a randomized counterbalanced order for on vs. off medication. However, our data remained inconclusive as to whether this observation constitutes beneficial treatment or acute stimulant withdrawal effects on sensorimotor gating.

Primary and secondary neural networks of auditory prepulse inhibition: a functional magnetic resonance imaging study of sensorimotor gating of the human acoustic startle response.

Feedforward inhibition deficits have been consistently demonstrated in a range of neuropsychiatric conditions using prepulse inhibition (PPI) of the acoustic startle eye-blink reflex when assessing sensorimotor gating. While PPI can be recorded in acutely decerebrated rats, behavioural, pharmacological and psychophysiological studies suggest the involvement of a complex neural network extending from brainstem nuclei to higher order cortical areas. The current functional magnetic resonance imaging study investigated the neural network underlying PPI and its association with electromyographically (EMG) recorded PPI of the acoustic startle eye-blink reflex in 16 healthy volunteers. A sparse imaging design was employed to model signal changes in blood oxygenation level-dependent (BOLD) responses to acoustic startle probes that were preceded by a prepulse at 120 ms or 480 ms stimulus onset asynchrony or without prepulse. Sensorimotor gating was EMG confirmed for the 120-ms prepulse condition, while startle responses in the 480-ms prepulse condition did not differ from startle alone. Multiple regression analysis of BOLD contrasts identified activation in pons, thalamus, caudate nuclei, left angular gyrus and bilaterally in anterior cingulate, associated with EMG-recorded sensorimotor gating. Planned contrasts confirmed increased pons activation for startle alone vs 120-ms prepulse condition, while increased anterior superior frontal gyrus activation was confirmed for the reverse contrast. Our findings are consistent with a primary pontine circuitry of sensorimotor gating that interconnects with inferior parietal, superior temporal, frontal and prefrontal cortices via thalamus and striatum. PPI processes in the prefrontal, frontal and superior temporal cortex were functionally distinct from sensorimotor gating.