Factors Contributing to Stress and Well-Being Among Trainee Psychiatrists in Victoria, Australia.

Doctors in training experience stress, as they balance the demands of working and studying at the same time. As evidenced by reports of suicides among trainee doctors, it is clear that the level of stress they experience is dangerously high. Long working hours, which can lead to exhaustion, burnout, and time taken away from meaningful activities and relationships outside of work, are a large contributor to trainee stress and increase the likelihood of mental illness and suicidal ideation. For psychiatry trainees, this workload burden is also compounded by a high emotional burden associated with the nature of their work, including patient suicides, aggression, and threats. This study sought to investigate the factors that contribute to the stress and well-being of psychiatry trainees, through in-depth interviews analyzed via qualitative, template analysis. The main sources of stress identified were workload, aspects related to the psychiatry training program, and workplace-based aggression. Supervision, external supports such as family and health professionals, and distraction or "switching off" were the main sources of well-being support. Overall, this study highlighted the importance of structural factors in the workplace and training program in psychiatry trainee stress and well-being levels. Workload and training commitments limited the amount of time trainees could devote to well-being-related activities, despite their awareness of these. This study contributes useful insights into how we can better look after the mental health and well-being of psychiatry trainees, as future leaders of our mental health system.

The Impact of Changes in Mental Health Legislation on Psychiatry Trainee Stress in Victoria, Australia.

In Victoria, Australia, the introduction of a new state Mental Health Act (MHA) in 2014 resulted in changes to the workload and type of work undertaken by trainee psychiatrists. In addition to long working hours, workload intensity is most often cited by trainees as a factor that leads to fatigue, with trainees often taking work home or doing overtime in order to fulfill work responsibilities and satisfy training requirements. This administrative burden is compounded by the high emotional burden associated with the practice of psychiatry, including patient suicides, aggression, and threats. This study aimed to explore the impact of these legislative changes on psychiatry trainees' stress and well-being, using a qualitative research methodology involving semi-structured interviews. Despite reporting that the length and number of reports they were preparing under the new MHA had increased, as had the amount of time spent at Tribunal hearings, psychiatry trainees were understanding of the necessity of MHA changes in improving patient rights. The trainees did not express a desire for the MHA changes to be reversed, but rather recognition by their workplaces that changes are also needed at a ground level-such as an increase in staff numbers-to accommodate for these. While mental health legislative changes are designed to improve the system and better protect patient rights, measures must also be taken to ensure that any policy-level changes are adequately adjusted for in hospital staffing levels.

Physical Activity for Cognitive Health: A Model for Intervention Design for People Experiencing Cognitive Concerns and Symptoms of Depression or Anxiety.

BACKGROUND: People experiencing cognitive concerns and symptoms of depression or anxiety are at risk for Alzheimer's disease and dementia. We know physical activity can benefit cognition but understanding how to best support engagement is an ongoing challenge. Evidence-based conceptual models of factors underpinning physical activity engagement in target populations can inform intervention tailoring to address this challenge. OBJECTIVE: This study (part of a pragmatic physical activity implementation trial) aimed to develop a specified model of physical activity engagement in people experiencing depressive or anxiety symptoms and cognitive concerns, to enable optimized dementia risk reduction intervention tailoring. METHODS: We employed a qualitative design, triangulating data from three sources: semi-structured individual interviews with people experiencing cognitive concerns and mild to moderate depressive or anxiety symptoms; review of published evidence; and the Capability, Opportunity and Motivation system of behavior, an existing behavioral science model. Findings were integrated to develop a contextualized model of mechanisms of action for optimizing engagement. RESULTS: Twenty-one participants were interviewed, and 24 relevant papers included. Convergent and complementary themes extended understanding of intervention needs. Findings highlighted emotional regulation, capacities to enact intentions despite barriers, and confidence in existing skills as areas of population-specific need that have not previously been emphasized. The final model provides specificity, directionality, and linked approaches for intervention tailoring. CONCLUSION: This study demonstrated that people experiencing cognitive concerns and symptoms of depression or anxiety require different interventions to improve physical activity engagement. This novel model can enable more precise intervention tailoring, and, ultimately, benefits for a key at-risk population.

Preferences and Perspectives of Australian General Practitioners Towards a New "Four-in-One" Risk Assessment Tool for Preventative Health: The LEAD! GP Project.

BACKGROUND: Dementia risk reduction is a public health priority and general practitioners (GPs) play a pivotal role in preventative healthcare. Therefore, risk assessment tools should be designed with GPs' preferences and perspectives in mind. OBJECTIVE: The LEAD! GP project aimed to investigate Australian GPs' preferences and perspectives relating to design, use and implementation of a new risk assessment tool that simultaneously calculates risk for four outcomes- dementia, diabetes mellitus, myocardial infarct, and stroke. METHODS: A mixed methods study using semi-structured interviews of a diverse group of 30 Australian GPs was conducted. Interview transcripts were analyzed thematically. Demographics and questions that elicited categorical answers were analyzed descriptively. RESULTS: Overall, GPs felt that preventative healthcare was important with some finding it rewarding, and others finding it difficult. GPs currently use many risk assessment tools. GPs' perception of the usefulness and negatives/barriers of tools related to clinical practice applicability, patient engagement, and practical aspects. The largest barrier was lack of time. GPs responded positively to the concept of a four-in-one tool and preferred it to be relatively short, supported by practice nurses and some patient involvement, linked to education resources, available in different formats, and integrated into practice software. CONCLUSION: GPs recognize the importance of preventative healthcare and the potential benefit of a new tool that simultaneously predicts risk for those four outcomes. Findings provide important guidance to inform the final development and piloting of this tool with potential to improve efficiency and practical integration of preventative healthcare for dementia risk reduction.

Access to a dementia-friendly garden on behavioural and psychological symptoms of dementia, falls and psychotropic medication use in residents of an aged care home in Melbourne, Australia.

OBJECTIVE: Residents of care homes need access to outdoors. This may improve behavioural and psychological symptoms of dementia (BPSD) and quality of life in residents living with dementia. Barriers including lack of accessibility and increased falls risk, which may be mitigated using dementia-friendly design. This prospective cohort study followed a group of residents in the first 6 months after the opening of a new dementia-friendly garden. METHOD: Nineteen residents participated. The Neuropsychiatric Inventory - Nursing Home Version (NPI-NH) and psychotropic medication use were collected at baseline, 3 and 6 months. The facility's falls rate during this time and feedback from staff and residents' next of kin were collected. RESULTS: Total NPI-NH scores decreased, though not significantly. Feedback was positive overall; the falls rate decreased. Usage of the garden was low. CONCLUSIONS: Despite its limitations, this pilot study adds to the literature about the importance of access to the outdoors for people who are experiencing BPSD. Staff remain concerned about falls risk despite the dementia-friendly design, and many residents do not access outdoors frequently. Further education may help to remove barriers to encouraging residents to access the outdoors.

Online counselling for family carers of people with young onset dementia: The RHAPSODY-Plus pilot study.

Objective: Compared to late life dementia, Young Onset Dementia (YOD) has its own distinct challenges, including a lack of specialised and age-appropriate support services. Carers of people with YOD experience higher levels of psychological and physical symptoms, and lower quality of life. This study (RHAPSODY-Plus) assessed the acceptability and feasibility of combining RHAPSODY (Research to Assess Policies and Strategies for Dementia in the Young; a web-based information and skill-building programme for carers of people with YOD) with individually tailored support sessions with health professionals (a social worker and a clinical psychologist) provided via online videoconferencing. Methods: Participants (n = 20) were informal carers aged over 18 years, who were caring for a person with YOD (either Alzheimer's disease or frontotemporal dementia type). Participants used the RHAPSODY programme for 4 weeks, then attended 2 support sessions. Participants and the health professionals then attended individual feedback sessions. Feedback was collected via open-ended and Likert-style questions. Results: The majority of carers rated the RHAPSODY-Plus programme as good to very good, demonstrating a high level of acceptability. Positive feedback about the programme included being able to receive personal advice additionally to the information provided in RHAPSODY. The healthcare professionals also thought the programme was acceptable and beneficial for access to support. Some limitations in the feasibility of videoconferencing included network and technical issues and the loss of non-verbal communication. Conclusions: This online pilot study had a high level of acceptability, demonstrating the potential of an individualised multi-modal intervention for carers of people with YOD which offers opportunities to overcome geographical and service access barriers.

Behavioral Activation in Nursing Homes to Treat Depression (BAN-Dep): Results From a Clustered, Randomized, Single-Blinded, Controlled Clinical Trial.

OBJECTIVES: To determine if behavioral activation (BA) delivered by trained staff decreases prevalence of clinically significant symptoms of depression among older adults living in residential aged care facilities (RACFs). METHODS: Clustered, randomized, single-blinded, controlled trial of BA for adults aged over 60 years living permanently in a RACF with symptoms of depression (Patient Health Questionnaire, PHQ-9 ≥ 5). BA was delivered over 8-12 weeks using a structured workbook. The proportion of residents with PHQ-9 ≥ 10 at weeks 12, 26, and 52, as well as anxiety symptoms (GAD-7), physical (PCS), and mental (MCS) quality of life, loneliness, and loss to follow-up were main outcomes of interest RESULTS: We recruited 54 RACFs (26 intervention) and 188 of their residents (89 intervention). Participants were aged 61-100 years and 132 (70.2%) were women. PHQ-9 ≥ 10 interacted with BA at week 12 (OR = 0.34, 95%CI = 0.11-1.07), but differences between the groups were not statistically significant at any time-point. GAD-7 ≥ 10 interacted with BA at week 26 (OR = 0.12, 95%CI = 0.02-0.58), but not at any other time-point. Overall, the intervention had no effect on the scores of the PHQ-9, GAD-7, PCS, MCS, and loneliness scale. Loss to follow-up was similar between groups. Adherence to all stages of the intervention was poor (36.2%). CONCLUSIONS: Disruption by the COVID-19 pandemic and staffing issues in RACFs undermined recruitment and adherence. In such a context, a BA program delivered by RACF staff was not associated with better mental health outcomes for residents over 52 weeks.

Psychotropic medication deprescribing in residential aged care facilities: An exploratory study of the knowledge and attitudes of family members of residents with dementia.

OBJECTIVES: General practitioners face many barriers to deprescribing psychotropic medications in people with dementia in nursing homes, including a lack of knowledge about their medication histories. This study explored the knowledge of family members about residents' medications and their willingness to support deprescribing. METHODS: Sixty-six family members of residents from seven residential aged care facilities participated in this cross-sectional study. Participation involved nomination of recognised medications, rating their effectiveness and rating level of support for deprescribing. RESULTS: Fifty-five per cent of medications were recognised by family members; significantly fewer psychotropics were recognised than non-psychotropic medications. Though rated as just as effective, support for deprescribing psychotropics was significantly higher. Most family members were agreeable to deprescribing with general practitioner support. CONCLUSIONS: Although there is a gap in family members' knowledge about psychotropic medications, overall they are supportive of deprescribing. Findings emphasise the need for psychoeducation among family members. Providing family members with a list of prescribed medications, specifying the type of and reason for prescription and side effects of each, is recommended to facilitate their advocacy for deprescribing on behalf of nursing home residents.

Perceived Need and Acceptability of an App to Support Activities of Daily Living in People With Cognitive Impairment and Their Carers: Pilot Survey Study.

BACKGROUND: Modern technologies, including smartphone apps, have the potential to assist people with cognitive impairment with activities of daily living, allowing them to maintain their independence and reduce carer burden. However, such tools have seen a slow rate of uptake in this population, and data on the acceptability of assistive technologies in this population are limited. OBJECTIVE: This pilot study included older adults with cognitive impairment and their carers, and explored the perceived needs for and acceptability of an app that was designed to be a simple assistive tool for activities of daily living. In particular, this study aimed to assess the acceptability of common app functions such as communication, reminder, navigation, and emergency tools in this population, and to compare patients' and carers' responses to them. METHODS: A total of 24 German participants with mild cognitive impairment or dementia and their family carers separately completed two short questionnaires. The first questionnaire asked the participants with cognitive impairment and their carers to self-rate the patients' cognitive impairment levels and affinity to technology. Following a demonstration of the app, participants rated the usability and acceptability of the app and its functions in a second questionnaire. RESULTS: Participants rated themselves as much less cognitively impaired than their carers did (P=.01), and insight into the level of support they received was low. The majority of the participants (19/24, 79%) and their carers (20/24, 83%) had low affinity to technology, and even after the demonstration, 63% (15/24) of the participants had low interest in using the app. A breakdown of acceptability responses by app function revealed that participants were more amenable to the reminder function, the emergency feature, and a wearable form of the app. Features that centered around carers monitoring participants' movements were reported to be less acceptable to participants. CONCLUSIONS: This study highlights the importance of focusing on acceptability and the consumer's perceptions in the development of assistive technology for older adults with cognitive impairment. Participants showed an aversion to functions they perceived as eroding their independence, while functions that more closely aligned with independence and autonomy were perceived as more acceptable.

Stress and Wellbeing of Psychiatry Trainees: A Literature Review.

Medical training in Australia has been clouded in recent times by media reporting on the tragic suicides of multiple trainees. This has brought attention to the stressful demands of the medical profession and the often-poor wellbeing of trainees, who must balance both study and work demands. Psychiatry trainees in particular face unique stressors in the workplace, being in a profession that carries a high emotional burden. Psychiatry trainees encounter suicides by patients and colleagues at an alarmingly high rate and commonly experience isolation, unrealistic workloads and stigma towards their chosen specialty. This literature review will highlight the extent to which these factors impact on psychiatry trainees. We will also explore the factors that contribute to their wellbeing, including the role of supervision, as well as leisurely and social activities. This review will look at the availability of these supports to psychiatry trainees and whether their lifestyles allow them time to spend on these activities. Though it is impossible to remove all stressors from psychiatry, interventions to improve trainee wellbeing must consider factors that improve resilience and support as well as target change to the culture in medicine that currently promotes stress and overwork. It must be recognised that trainees who feel supported and mentally well will perform better in the workplace in the long run, and, in this review, we will speculate about how workplace changes that are occurring for psychiatry trainees in Victoria, Australia, may affect their wellbeing.

Behavioural activation in nursing homes to treat depression (BAN-Dep): study protocol for a pragmatic randomised controlled trial.

INTRODUCTION: Depression is a common disorder among older people living in residential aged care facilities. Several trials have demonstrated the effectiveness of behavioural therapies in treating depressive symptoms in older adults living in the community and in residential aged care. Behavioural Activation is demonstrably effective even when delivered by non-specialists (staff without formal psychological training), although strategies for adapting its use in residential aged care facilities are yet to be explored. This study will determine whether training residential care staff in the use of a structured Behavioural Activation programme is more effective at decreasing depressive symptoms among older residents than internet-based training about depression recognition and management alone. METHOD AND ANALYSIS: The behavioural activation in nursing homes to treat depression (BAN-Dep) trial is a pragmatic two-arm parallel clustered randomised controlled trial. It will recruit 666 residents aged 60 or older from 100 residential aged care facilities, which will be randomly assigned to the Behavioural Activation or control intervention. Staff in both treatment groups will be encouraged to complete the Beyondblue Professional Education to Aged Care e-learning programme to improve their recognition of and ability to respond to depression in older adults. Selected staff from intervention facilities will undergo additional training to deliver an 8-module Behavioural Activation programme to residents with subthreshold symptoms of depression-they will receive ongoing Mental support from trained Behavioural Activation therapists. Outcome measures will be collected by blind research officer at baseline and after 3, 6 and 12 months. The Patient Health Questionnaire-9 is the primary outcome measure of the study. ETHICS AND DISSEMINATION: The trial will comply with the principles of the Declaration of Helsinki for Human Rights and is overseen by the University of Western Australia (reference RA/4/20/4234) and Melbourne Health (reference number HREC/18/MH/47) Ethics Committees. The results of this research project will be disseminated through publications and/or presentations in a variety of media to health professionals, academics, clinicians and the public. Only de-identified group data will be presented. TRIAL REGISTRATION: ACTRN12618000634279.