Computerized Cognitive Behavioral Therapy for Anxiety and Depression in Farming Communities: Mixed Methods Feasibility Study of Participant Use and Acceptability.

BACKGROUND: Farmers have higher rates of depression than nonfarmers and higher rates of suicide than the general population. Several barriers to help seeking have been identified in farmers, which may be overcome by offering web-based mental health support. Computerized cognitive behavioral therapy (cCBT) is an effective intervention used to prevent and treat mild to moderate depression but has not been evaluated in the farming community. OBJECTIVE: This study explored the feasibility of delivering a cCBT course tailored to farmers using a mixed methods approach. METHODS: Farmers (aged ≥18 years) with no, minimal, or moderately severe depressive symptoms (Patient Health Questionnaire-9 [PHQ-9] score <20) were recruited using web-based and offline advertisements and given access to a cCBT course consisting of 5 core modules and automated and personalized email support. Depression (PHQ-9), anxiety (General Anxiety Disorder-7), and social functioning (Work and Social Adjustment Scale) were measured at baseline and the 8-week follow-up. Wilcoxon signed rank tests assessed changes in scores for all outcome measures over time. Telephone interviews focusing on participant use and satisfaction with the course were analyzed using thematic analysis. RESULTS: Overall, 56 participants were recruited; 27 (48%) through social media. Overall, 62% (35/56) of participants logged into the course. At baseline, almost half of the participants reported experiencing minimal depressive symptoms (25/56, 45%) and mild anxiety (25/56, 45%), and just over half (30/56, 54%) reported mild to moderate functional impairment. Posttreatment data were available for 27% (15/56) of participants (41/56, 73% attrition rate). On average, participants experienced fewer depressive symptoms (P=.38) and less functional impairment (P=.26) at the 8-week follow-up; these results were not statistically significant. Participants experienced significantly fewer symptoms of anxiety at the 8-week follow-up (P=.02). Most participants (13/14, 93%) found the course helpful and easy to access (10/13, 77%) and the email support helpful (12/14, 86%). Qualitative interviews identified heavy workloads and mental health stigma within the farming community as barriers to help seeking. Participants thought that web-based support would be helpful, being convenient and anonymous. There were concerns that older farmers and those with limited internet connections may have difficulty accessing the course. Improvements regarding the layout and content of the course were suggested. Dedicated support from someone with farming knowledge was recommended to improve retention. CONCLUSIONS: cCBT may be a convenient way of supporting mental health within farming communities. However, challenges in recruiting and retaining farmers may indicate that cCBT supported only by email may not be an acceptable mode of mental health care delivery for many; however, it was valued by respondents. Involving farming organizations in planning, recruitment, and support may address these issues. Mental health awareness campaigns targeting farming communities may also help reduce stigma and improve recruitment and retention.

Frequent users of Mental Health Liaison Services within Emergency Departments.

This study aimed to use nuanced statistical methods in a large UK sample to identify and explore the factors associated with different types of frequent user of Emergency Departments (EDs) who are referred to Mental Health Liaison Services (MHLS). A retrospective 5-year longitudinal study was conducted of all attenders (n = 23,718) of four London EDs who were referred to their MHLS. Longitudinal group-based trajectory analysis of monthly MHLS referrals enabled identification of factors which may contribute to membership of the resulting groups. Analysis revealed six clusters representing distinct attendance patterns; three clusters of these were identified as frequent attender groups (occasional, intermediate, heavy) containing 1119 people (4.7%). This 4.7% of the sample accounted for 24.2% of all admissions. Factors significantly related to membership of each of these groups were: having been involuntarily detained under the Mental Health Act, a higher number of care coordinators, and a diagnosis of substance abuse. The study revealed three clusters of frequent ED users with a MHLS referral who were more likely to have certain clinical and social care needs. A small proportion of clients identified as frequent users (4.7%) were responsible for nearly a quarter of all admissions (24.2%) during this timeframe.

Statistical approaches for identifying heavy users of inpatient mental health services.

BACKGROUND: A lack of consensus exists concerning how to identify "heavy users" of inpatient mental health services. AIM: To identify a statistical approach that captures, in a clinically meaningful way, "heavy" users of inpatient services using number of admissions and total time spent in hospital. METHODS: "Simple" statistical methods (e.g. top 2%) and data driven methods (e.g. the Poisson mixture distribution) were applied to admissions made to adult acute services of a London mental health trust. RESULTS: The Poisson mixture distribution distinguished "frequent users" of inpatient services, defined as having 4 + admissions in the study period. It also distinguished "high users" of inpatient services, defined as having 52 + occupied bed days. Together "frequent" and "high" users were classified as "heavy users". CONCLUSIONS: Data driven criteria such as the Poisson mixture distribution can identify "heavy" users of inpatient services. The needs of this group require particular attention.

Characteristics of people who rapidly and frequently reattend the emergency department for mental health needs.

OBJECTIVE: This paper identifies the characteristics of emergency department (ED) attendees with a referral to their Mental Health Liaison Service (MHLS) who are at increased risk for rapidly reattending, attending frequently, or attending intensely at this service (which is defined here as rapid and frequent reattendance). METHODS: A retrospective 5-year longitudinal study was conducted of all visitors (n=24 010) attending four busy EDs with a referral to their MHLS from the beginning of 2009 until the end of 2013. A Cox proportional hazards regression was used to identify factors associated with intense use, and a negative binomial regression was used to identify factors associated with frequent attendance. RESULTS: People with certain characteristics were more likely to make 'intense' use of mental health emergency services, which we define as shorter time to reattendance and a higher number of visits over 5 years. The people more likely to make intense use are more likely to have certain clinical diagnoses such as substance misuse, stress disorder, personality disorder and learning disability, to have certain social characteristics such as not being in a relationship, or living alone, and to have healthcare issues such as having been detained under the Mental Health Act and having a greater number of care coordinators over 5 years. CONCLUSION: Individuals with certain clinical and social characteristics were significantly more likely to reattend EDs and have referral to MHLS rapidly and frequently (i.e. intensely).

Handedness as a marker of cerebral lateralization in children with and without autism.

We employed a multiple case studies approach to investigate lateralization of hand actions in typically and atypically developing children between 4 and 5 years of age. We report on a detailed set of over 1200 hand actions made by four typically developing boys and four boys with autism. Participants were assessed for unimanual hand actions to both objects and the self (self-directed behaviors). Individual and group analyses suggest that typically developing children have a right hand dominance for hand actions to objects and a left hand dominance for hand actions for self-directed behaviors, revealing a possible dissociation for functional specialization of the left and right hemispheres respectively. Children with autism demonstrated mixed-handedness for both target conditions, consistent with the hypothesis that there is reduced cerebral specialization in these children. The findings are consistent with the view that observed lateralized motor action can serve as an indirect behavioral marker for evidence of cerebral lateralization.