Partner symptom accommodation in generalized anxiety disorder: a preliminary examination of correlates with symptoms and cognitive behavioural therapy outcome.

BACKGROUND: Symptom accommodation is suggested to maintain anxiety pathology and interfere with treatment effectiveness for anxiety and related disorders. However, little is known about symptom accommodation in generalized anxiety disorder (GAD). AIM: This study investigated the associations between romantic partner symptom accommodation, GAD symptoms, intolerance of uncertainty (IU), relationship satisfaction, and cognitive behavioural therapy (CBT) outcomes from the perspective of the person with GAD. METHOD: One hundred and twelve people with GAD participated in group CBT and completed measures at pre- and post-treatment. RESULTS: All participants endorsed that their partner engaged in symptom accommodation to some extent, and the most commonly endorsed type was providing reassurance. Greater self-reported partner symptom accommodation was associated with greater GAD symptoms, chronic worry severity, IU, and relationship satisfaction at baseline. Partner symptom accommodation was found to significantly decrease over treatment; however, less improvement in symptom accommodation from pre- to post-treatment was associated with worse treatment outcomes. DISCUSSION: This study is the first to show that partner symptom accommodation is prevalent in adults with GAD and to elucidate the presentation and frequency of behaviours. The findings provide preliminary evidence that targeting partner symptom accommodation in treatment may improve CBT outcomes.

Effectiveness and predictors of group cognitive behaviour therapy outcome for generalised anxiety disorder in an out-patient hospital setting.

BACKGROUND: Cognitive behavioural therapy (CBT) is an empirically supported treatment for generalized anxiety disorder (GAD). Little is known about the effectiveness of CBT for GAD in real-world treatment settings. AIM: This study investigated the effectiveness of group CBT and predictors of treatment response in an out-patient hospital clinic. METHOD: Participants (n = 386) with GAD participated in 12 sessions of group CBT at an out-patient clinic. Of those who provided at least partial data (n = 326), 84.5% completed treatment. Most questionnaires were completed at pre- and post-treatment; worry severity was assessed weekly. RESULTS: Group CBT led to improvements in chronic worry (d = -0.91, n = 118), depressive symptoms (d = -1.22, n = 172), GAD symptom severity (d = -0.65, n = 171), intolerance of uncertainty (IU; d = -0.46, n = 174) and level of functional impairment (d = -0.35, n = 169). Greater pre-treatment GAD symptom severity (d = -0.17, n = 293), chronic worry (d = -0.20, n = 185), functional impairment (d = -0.12, n = 292), and number of comorbid diagnoses (d = -0.13, n = 299) predicted greater improvement in past week worry over treatment. Biological sex, age, depression symptom severity, number of treatment sessions attended, and IU did not predict change in past week worry over time. DISCUSSION: These findings provide support for the effectiveness of group CBT for GAD and suggest the outcomes are robust and are either not impacted or are slightly positively impacted by several demographic and clinical factors.

Feasibility of salivary cortisol collection in patients and companions attending dementia diagnostic meetings in memory clinics.

OBJECTIVES: Receiving a diagnosis of dementia is life-changing for the individual and their companion. The aim of the study was to explore the feasibility of collecting salivary cortisol from patients who are informed if they have dementia and their companions. Patients and companions collected nine saliva samples in three batches: 1-2 weeks before, immediately before, and immediately after the diagnostic meeting. Each batch consisted of three samples taken in the evening, after awaking and 30 mins post-waking. RESULTS: 22.7% (N = 10) of 44 invited patients and nine companions agreed, with 18.2% patients (N = 8) and 15.9% companions (N = 7) providing samples. Participants found that saliva collection was demanding and disrupted routines. On a purely descriptive level, some indications of an increased cortisol stress response in patients diagnosed with dementia were found in this very small sample. Researchers should expect low recruitment rates in this elderly population. Simpler collection procedures, e.g. pre-labelled packages with date/time, possible omission of morning samples and objective rather than self-report assessment of waking and saliva collection times-using actigraphy wrist-watches bleeps to prompt people at the timepoints and electronic track caps-might improve adherence and improve the accuracy of timepoints when swabs were actually collected.

Optimizing screening for depression, anxiety disorders, and post-traumatic stress disorder in inpatient addiction treatment: A preliminary investigation.

OBJECTIVE: Substance use disorders (SUD) are frequently comorbid with other psychiatric conditions, but a comprehensive diagnostic assessment is often not feasible clinically. Efficient psychometrically-validated screening tools exist for commonly comorbid conditions, but cutoff accuracies have typically not been evaluated in addiction treatment settings. This study examined the performance of several widely-used screening measures in relation to diagnostic status from a clinical interview to identify and validate cutoff scores in an inpatient SUD treatment setting. METHOD: Participants were 99 patients in a large residential SUD treatment program in Ontario, Canada. Participants completed a screening battery, including the Patient Health Questionnaire - 9 (PHQ-9), Generalized Anxiety Disorder - 7 (GAD-7), and Post-Traumatic Stress Disorder Checklist-5 (PCL-5), and underwent a semi-structured diagnostic clinical interview. Receiver operating characteristic curves were used to determine optimal cutoff scores on the screening tool against the interview-based diagnosis. RESULTS: Area under the curve (AUC) was statistically significant for all screens and were as follows: PHQ-9 = 0.70 (95% CI = 0.59-0.80), GAD-7 = 0.74 (95% CI = 0.63-0.84), and PCL-5 = 0.79 (95% CI = 0.66-0.91). The optimal accuracy cutoff scores based on sensitivity and specificity were: PHQ-9 ≥ 16, GAD-7 ≥ 9, the PCL-5 ≥ 42. CONCLUSIONS: In general, the candidate screeners performed acceptably in this population. However, the optimal cutoff scores were notably higher than existing guidelines for depression and PTSD, potentially due to the general elevations in negative affectivity among individuals initiating SUD treatment. Further validation of these cutoff values is warranted. PUBLIC HEALTH SIGNIFICANCE: This study provides modified screening cutoff scores for major depression, anxiety disorders, and post-traumatic stress disorder in addiction treatment settings.

Objective and subjective vasomotor symptom outcomes in the CBT-Meno randomized controlled trial.

Objective: Vasomotor symptoms (hot flashes, night sweats) are common during the menopausal transition. Pharmacotherapy is effective but is associated with health risks for some women. There is an increasing demand for non-pharmacological interventions. The CBT-Meno protocol is a psychological intervention targeting a range of common menopausal symptoms. We compared the impact of CBT-Meno vs. waitlist on objective and subjective measures of vasomotor symptoms and on the relationship between vasomotor symptoms and sleep difficulties.Materials: The participants were 36 perimenopausal or postmenopausal women with co-occurring depressive symptoms who participated in the CBT-Meno trial (clinicaltrials.gov NCT02480192). Subjective measures included the Hot Flash Related Daily Interference Scale, the Greene Climacteric Scale, and the Pittsburgh Sleep Quality Inventory. Objective (physiological) and 'in-the-moment' measures of vasomotor symptoms were assessed with sternal skin conductance.Results: Greater improvements in vasomotor 'bothersomeness' and 'interference' were observed in the CBT-Meno condition compared to the waitlist condition. No between-group differences were observed in vasomotor frequency (subjectively or objectively recorded) or severity ratings. Sleep disturbance was unrelated to objectively measured vasomotor symptom frequency.Conclusion: The CBT-Meno trial improved subjective but not objective (physiological) measures of vasomotor symptoms. Self-reported sleep difficulties were unrelated to subjective or objective vasomotor symptoms.

How accessible and acceptable are current GP referral mechanisms for IAPT for low-income patients? Lay and primary care perspectives.

Background: Improving Access to Psychological Therapies (IAPT) constitutes a key element of England's national mental health strategy. Accessing IAPT usually requires patients to self-refer on the advice of their GP. Little is known about how GPs perceive and communicate IAPT services with patients from low-income communities, nor how the notion of self-referral is understood and responded to by such patients.Aims: This paper examines how IAPT referrals are made by GPs and how these referrals are perceived and acted on by patients from low-income backgroundsMethod: Findings are drawn from in-depth interviews with low-income patients experiencing mental distress (n = 80); interviews with GPs (n = 10); secondary analysis of video-recorded GP-patient consultations for mental health (n = 26).Results: GPs generally supported self-referral, perceiving it an important initial step towards patient recovery. Most patients however, perceived self-referral as an obstacle to accessing IAPT, and felt their mental health needs were being undermined. The way that IAPT was discussed and the pathway for referral appears to affect uptake of these services.Conclusions: A number of factors deter low-income patients from self-referring for IAPT. Understanding these issues is necessary in enabling the development of more effective referral and support mechanisms within primary care.

What can clinicians do to improve outcomes across psychiatric treatments: a conceptual review of non-specific components.

AIMS: Psychiatric treatments have specific and non-specific components. The latter has been addressed in an extensive literature on the placebo-effect in pharmacology and on common factors in psychotherapy. In the practice of mental health care, pharmacological, psychotherapeutic and social treatments are combined in complex interventions. This paper aims to review non-specific components across diverse psychiatric treatments and consider implications for practice and research. METHODS: We conducted a non-systematic review of non-specific components across psychiatric treatments, their impact on treatment processes and outcomes, and interventions to improve them. RESULTS: The identified research is heterogeneous, both in design and quality. All non-specific components capture aspects of how clinicians communicate with patients. They are grouped into general verbal communication - focusing on initial contacts, empathy, clarity of communication, and detecting cues about unspoken concerns - non-verbal communication, the framing of treatments and decision-making. The evidence is stronger for the impact of these components on process measures - i.e. therapeutic relationship, treatment satisfaction and adherence than on clinical outcomes - i.e. symptoms and relapse. A small number of trials suggest that brief training courses and simple methods for structuring parts of clinical consultations can improve communication and subsequently clinical outcomes. CONCLUSIONS: Methodologically, rigorous research advancing current understandings of non-specific components may increase effectiveness across different treatments, potentially benefitting large numbers of patients. Brief training for clinicians and structuring clinical communication should be used more widely in practice.

Three-dimensional character of the deformation twin in magnesium.

Deformation twins are three-dimensional domains, traditionally viewed as ellipsoids because of their two-dimensional lenticular sections. In this work, we performed statistical analysis of twin shapes viewing along three orthogonal directions: the 'dark side' (DS) view along the twin shear direction (η1), the twinning plane normal (TPN) view (k1) and the 'bright side' (BS) view along the direction λ(=k1 × Î·1). Our electron back-scatter diffraction results show that twins in the DS and BS views normally exhibit a lenticular shape, whereas they show an irregular shape in the TPN view. Moreover, the findings in the TPN view revealed that twins grow faster along λ the lateral direction than along η1 the forward propagation direction at the initial stages of twin growth. These twin sections are irregular, indicating that growth is locally controlled and the overall shape is not perfectly ellipsoidal. We explain these findings using atomistic models, and ascribe them to differences in the mobility of the edge and screw components of the twinning dislocations.

Characterizing the role of adjoining twins at grain boundaries in hexagonal close packed materials.

Hexagonal close packed (HCP) Mg and Zr are being used in transportation and nuclear industries, respectively. The ductility and formability of these materials is significantly limited by the activation of prevalent deformation twinning. Twins in HCP polycrystals usually nucleate at grain boundaries (GBs), propagate into the grain, and they either terminate at opposing GBs (isolated-twins) or transmit into a neighboring grain (adjoining-twin-pairs: ATPs). Because twin interfaces provide a path for crack propagation, twin transmission is relevant to material ductility. This study combines electron backscatter diffraction (EBSD) based statistical analysis of twinning microstructures and crystal plasticity modeling, to characterize twin thickening processes away from and near GBs. Analysis of deformed Mg and Zr microstructures reveals that local twin thicknesses at GBs are statistically larger for ATPs compared to isolated-twins. Further, thicknesses are found to decrease with increasing GB misorientation angle. Full-field Fast-Fourier-Transform micromechanics modeling shows that shear-transformation induced backstress are locally relaxed at GBs for ATPs, but not for isolated-twins. As a consequence, ATPs can thicken locally at GBs and the preferential site for twin thickening shifts from the middle of the twin to common GB.

Patient coping and expectations predict recovery after major orthopaedic trauma.

BACKGROUND: Persistent post-surgical pain and associated disability are common after a traumatic fracture repair. Preliminary evidence suggests that patients' beliefs and perceptions may influence their prognosis. METHODS: We used data from the Fluid Lavage of Open Wounds trial to determine, in 1560 open fracture patients undergoing surgical repair, the association between Somatic PreOccupation and Coping (captured by the SPOC questionnaire) and recovery at 1 yr. RESULTS: Of the 1218 open fracture patients with complete data available for analysis, 813 (66.7%) reported moderate to extreme pain at 1 yr. The addition of SPOC scores to an adjusted regression model to predict persistent pain improved the concordance statistic from 0.66 to 0.74, and found the greatest risk was associated with high (≥74) SPOC scores [odds ratio: 5.63; 99% confidence interval (CI): 3.59-8.84; absolute risk increase 40.6%; 99% CI: 30.8%, 48.6%]. Thirty-eight per cent (484 of 1277) reported moderate to extreme pain interference at 1 yr. The addition of SPOC scores to an adjusted regression model to predict pain interference improved the concordance statistic from 0.66 to 0.75, and the greatest risk was associated with high SPOC scores (odds ratio: 6.06; 99% CI: 3.97-9.25; absolute risk increase: 18.3%; 95% CI: 11.7%, 26.7%). In our adjusted multivariable regression models, SPOC scores at 6 weeks post-surgery accounted for 10% of the variation in short form-12 physical component summary scores and 14% of short form-12 mental component summary scores at 1 yr. CONCLUSIONS: Amongst patients undergoing surgical repair of open extremity fractures, high SPOC questionnaire scores at 6 weeks post-surgery were predictive of persistent pain, reduced quality of life, and pain interference at 1 yr. CLINICAL TRIAL REGISTRATION: NCT00788398.

Deformation twinning and grain partitioning in a hexagonal close-packed magnesium alloy.

Pervasive deformation twinning in magnesium greatly affects its strength and formability. The local stress fields associated with twinning play a key role on deformation behavior and fracture but are extremely difficult to characterize experimentally. In this study, we perform synchrotron experiments with differential-aperture X-ray microscopy to measure the 3D stress fields in the vicinity of a twin with a spatial resolution of 0.5 micrometer. The measured local stress field aids to identify the sequence of events involved with twinning. We find that the selected grain deforms elastically before twinning, and the twin formation splits the grain into two non-interacting domains. Under further straining one domain of the grain continued to deform elastically, whereas the other domain deforms plastically by prismatic slip. This heterogeneous deformation behavior may be mediated by the surrounding medium and it is likely to lead to asymmetric twin growth.

Perioperative psychotherapy for persistent post-surgical pain and physical impairment: a meta-analysis of randomised trials.

BACKGROUND: Persistent post-surgical pain affects 10-80% of individuals after common operations, and is more common among patients with psychological factors such as depression, anxiety, or catastrophising. METHODS: We conducted a systematic review and meta-analysis of randomised, controlled trials to evaluate the efficacy of perioperative psychotherapy for persistent post-surgical pain and physical impairment. Paired independent reviewers identified studies, extracted data, and assessed risk of bias. The Grading of Recommendations, Assessment, Development and Evaluation system was used to assess the quality of evidence. RESULTS: Our search of five electronic databases, up to September 1, 2016, found 15 trials (2220 patients) that were eligible for review. For both persistent post-surgical pain and physical impairment, perioperative education was ineffective, while active psychotherapy suggested a benefit (test of interaction P=0.01 for both outcomes). Moderate quality evidence showed that active perioperative psychotherapy (cognitive-behaviour therapy, relaxation therapy, or both) significantly reduced persistent post-surgical pain [weighted mean difference (WMD) -1.06 cm on a 10 cm visual analogue scale for pain, 95% confidence interval (CI) -1.56 to -0.55 cm; risk difference (RD) for achieving no more than mild pain (≤3 cm) 14%, 95% CI 8-21%] and physical impairment [WMD -9.87% on the 0-100% Oswestry Disability Index, 95% CI -13.42 to -6.32%, RD for achieving no more than mild disability (≤20%) 21%, 95% CI 13-29%]. CONCLUSIONS: Perioperative cognitive behavioural therapy and relaxation therapy are effective for reducing persistent pain and physical impairment after surgery. Future studies should explore targeted psychotherapy for surgical patients at higher risk for poor outcome. CLINICAL TRIAL REGISTRATION: PROSPERO CRD42016047335.

Clinical relevance of findings in trials of CBT for depression.

Cognitive behavioural therapy (CBT) is beneficial in depression. Symptom scores can be translated into Clinical Global Impression (CGI) scale scores to indicate clinical relevance. We aimed to assess the clinical relevance of findings of randomised controlled trials (RCTs) of CBT in depression. We identified RCTs of CBT that used the Hamilton Rating Scale for Depression (HAMD). HAMD scores were translated into Clinical Global Impression - Change scale (CGI-I) scores to measure clinical relevance. One hundred and seventy datasets from 82 studies were included. The mean percentage HAMD change for treatment arms was 53.66%, and 29.81% for control arms, a statistically significant difference. Combined active therapies showed the biggest improvement on CGI-I score, followed by CBT alone. All active treatments had better than expected HAMD percentage reduction and CGI-I scores. CBT has a clinically relevant effect in depression, with a notional CGI-I score of 2.2, indicating a significant clinical response. The non-specific or placebo effect of being in a psychotherapy trial was a 29% reduction of HAMD.

Grain neighbour effects on twin transmission in hexagonal close-packed materials.

Materials with a hexagonal close-packed (hcp) crystal structure such as Mg, Ti and Zr are being used in the transportation, aerospace and nuclear industry, respectively. Material strength and formability are critical qualities for shaping these materials into parts and a pervasive deformation mechanism that significantly affects their formability is deformation twinning. The interaction between grain boundaries and twins has an important influence on the deformation behaviour and fracture of hcp metals. Here, statistical analysis of large data sets reveals that whether twins transmit across grain boundaries depends not only on crystallography but also strongly on the anisotropy in crystallographic slip. We show that increases in crystal plastic anisotropy enhance the probability of twin transmission by comparing the relative ease of twin transmission in hcp materials such as Mg, Zr and Ti.

Characterizing the boundary lateral to the shear direction of deformation twins in magnesium.

The three-dimensional nature of twins, especially the atomic structures and motion mechanisms of the boundary lateral to the shear direction of the twin, has never been characterized at the atomic level, because such boundary is, in principle, crystallographically unobservable. We thus refer to it here as the dark side of the twin. Here, using high-resolution transmission electron microscopy and atomistic simulations, we characterize the dark side of deformation twins in magnesium. It is found that the dark side is serrated and comprised of coherent twin boundaries and semi-coherent twist prismatic-prismatic boundaries that control twin growth. The conclusions of this work apply to the same twin mode in other hexagonal close-packed materials, and the conceptual ideas discussed here should hold for all twin modes in crystalline materials.

What can patients do to facilitate shared decision making? A qualitative study of patients with depression or schizophrenia and psychiatrists.

PURPOSE: Patient involvement in decision making is endorsed by patients and professionals. While research has recently been conducted on how professionals can promote shared decision making (SDM), little is known about how patients can also facilitate SDM. METHODS: Seven focus groups were conducted: 3 with psychiatrists and 4 with patients with schizophrenia or depression. The focus groups were transcribed and independently coded line by line by 2 researchers. Data were analyzed using content analysis. RESULTS: Seven themes related to patient attitudes and behaviors were identified: honesty and openness with one's psychiatrist and oneself, trust in one's psychiatrist and patience with the treatment, respect and politeness, informing the psychiatrist and giving feedback, engagement/active participation during the consultation, gathering information/preparing for the consultation and implementing decisions. Barriers (e.g., avolition, lack of decisional capacity, powerlessness during involuntary treatment) and facilitators of active patient behavior were also identified. CONCLUSIONS: There are various ways in which patients can facilitate SDM/play a more active role in decision making, with patients emphasizing being open and honest and psychiatrists emphasizing being active in the consultation. Interventions to increase active patient behavior may enhance SDM in mental health care.

Non-verbal communication in meetings of psychiatrists and patients with schizophrenia.

OBJECTIVE: Recent evidence found that patients with schizophrenia display non-verbal behaviour designed to avoid social engagement during the opening moments of their meetings with psychiatrists. This study aimed to replicate, and build on, this finding, assessing the non-verbal behaviour of patients and psychiatrists during meetings, exploring changes over time and its association with patients' symptoms and the quality of the therapeutic relationship. METHOD: 40-videotaped routine out-patient consultations, involving patients with schizophrenia, were analysed. Non-verbal behaviour of patients and psychiatrists was assessed during three fixed, 2-min intervals using a modified Ethological Coding System for Interviews. Symptoms, satisfaction with communication and the quality of the therapeutic relationship were also measured. RESULTS: Over time, patients' non-verbal behaviour remained stable, whilst psychiatrists' flight behaviour decreased. Patients formed two groups based on their non-verbal profiles, one group (n = 25) displaying pro-social behaviour, inviting interaction and a second (n = 15) displaying flight behaviour, avoiding interaction. Psychiatrists interacting with pro-social patients displayed more pro-social behaviours (P < 0.001). Patients' pro-social profile was associated reduced symptom severity (P < 0.05), greater satisfaction with communication (P < 0.001) and positive therapeutic relationships (P < 0.05). CONCLUSION: Patients' non-verbal behaviour during routine psychiatric consultations remains unchanged, and is linked to both their psychiatrist's non-verbal behaviour and the quality of the therapeutic relationship.

Insight, duration of untreated psychosis and attachment in first-episode psychosis: prospective study of psychiatric recovery over 12-month follow-up.

BACKGROUND: Increasing evidence shows attachment security influences symptom expression and adaptation in people diagnosed with schizophrenia and other psychoses. AIMS: To describe the distribution of secure and insecure attachment in a cohort of individuals with first-episode psychosis, and to explore the relationship between attachment security and recovery from positive and negative symptoms in the first 12 months. METHOD: The study was a prospective 12-month cohort study. The role of attachment, duration of untreated psychosis (DUP), baseline symptoms and insight in predicting and mediating recovery from symptoms was investigated using multiple regression analysis and path analysis. RESULTS: Of the 79 participants, 54 completed the Adult Attachment Interview (AAI): 37 (68.5%) were classified as insecure, of which 26 (48.1%) were insecure/dismissing and 11 (20.4%) insecure preoccupied. Both DUP and insight predicted recovery from positive symptoms at 12 months. Attachment security, DUP and insight predicted recovery from negative symptoms at 12 months. CONCLUSIONS: Attachment is an important construct contributing to understanding and development of interventions promoting recovery following first-episode psychosis.

Allopurinol enhanced thiopurine treatment for inflammatory bowel disease: safety considerations and guidelines for use.

WHAT IS KNOWN AND OBJECTIVE: The thiopurine medications are standard inflammatory bowel disease treatments. Therapeutic failure is observed, however, often because of variable drug metabolism. Allopurinol can enhance the potency of thiopurine treatment. Our objective is to review the relevant literature, and our own experience, to determine if allopurinol enhancement of thiopurine treatment is a reasonable therapeutic strategy. COMMENT: Published reports of, and our own experience using, allopurinol-thiopurine combination therapy indicate that the addition of allopurinol will enhance thiopurine treatment in up to 60% of patients. There are risks to this approach, but with appropriate monitoring, these risks should approximate those observed with thiopurine therapy alone. WHAT IS NEW AND CONCLUSION: Combination therapy with allopurinol and a thiopurine is a reasonable alternative for inflammatory bowel disease patients not responding to thiopurine monotherapy. Physicians experienced in thiopurine treatment, who have familiarity with thiopurine metabolism, and are willing to engage in appropriate therapeutic monitoring, should consider this strategy.

How effective is high-support community-based step-down housing for women in secure mental health care? A quasi-experimental pilot study.

In the past decade UK government policy has been to develop alternative care for women detained in secure psychiatric hospital. This study evaluated the relative benefits of community-based step-down housing. Comparisons were made between female patients in community step-down housing and a control group in secure hospital who were on the waiting list for the houses. For each woman in the sample, a range of assessments was conducted on three separate occasions over a 12-month period. We noted a gradual improvement over time in women in both settings. However, by the final assessment psychological well-being and security needs were significantly better in the community group (P < 0.05). Although risks for violence and social functioning were also somewhat better in this group throughout the study, no statistically significant differences between the groups were found in these areas at any assessment time. This study has generated evidence in support of the further development of high-support step-down community housing for women in secure psychiatric care. This initiative may provide greater personal freedom and enhanced relational security for the women concerned while also facilitating improvements in their psychological well-being, with no increased risk to the women themselves or to the wider community.