Comparative, clinical feasibility study of three tools for delivery of cognitive behavioural therapy for mild to moderate depression and anxiety provided on a self-help basis

Background In response to a research recommendation made by a UK healthcare policy agency (National Institute for Health and Clinical Excellence (NICE)), this study compared the effectiveness of computer‐based cognitive behavioural therapy (CBT) with other self‐help treatment options for mild to moderate depression and anxiety.Method Comparative, clinical feasibility study of three self‐help CBT tools with six‐month follow‐up. Out of an initial sample of 180 adults referred by their general practitioners, 100 met the inclusion criteria and after consenting to take part were allocated one of three self‐help CBT tools: the Beating the Blues® (BtB) computer programme;¹ workbooks on overcoming depression and anxiety; and the Livinglifetothefull free access internet website.²Results Only 50 of the 100 consented participants completed the allocated intervention protocols, however, drop‐out rates were not significantly different between the groups of participants allocated each of the three self‐help CBT tools. Adults aged over 24 years (χ² = 14.5; df = 2; P = 0.001) and with symptom duration greater than four years (χ² = 3.96; df = 1; P = 0.047) were significantly more likely to complete any of the three interventions. There was a highly significant reduction in mean Clinical Outcomes in Routine Evaluation–Outcome Measure (CORE–OM) score at week eight compared to entry in all three groups (t (49) = 9.150; P ≤0.001). Adjusting for entry scores, there was no significant difference between the three groups in CORE–OM score improvement at week eight. There was no significant association between CORE–OM score improvement at week eight and number of general practitioner (GP) consultations at six months. There was no significant association between whether participants completed the programme and number of GP consultations at six months.Conclusions The results demonstrated that within a two‐month follow‐up period, three different tools delivering self‐help CBT all produced significant clinical benefit for adults with mild to moderate depression and anxiety. The study had limited statistical power, but none of the modalities for delivering supported self‐help CBT appeared superior to another. There was no evidence to suggest that any of these interventions would be likely to reduce subsequent service uptake. Nevertheless, this pilot study has shown sufficient benefit from each of the self‐administered CBT tools to justify larger trials of their use.     

Therapist-supported Internet-based cognitive behaviour therapy yields similar effects as face-to-face therapy for psychiatric and somatic disorders: an updated systematic review and meta-analysis

Providing therapist-guided cognitive behaviour therapy via the Internet (ICBT) has advantages, but a central research question is to what extent similar clinical effects can be obtained as with gold-standard face-to-face cognitive behaviour therapy (CBT). In a previous meta-analysis published in this journal, which was updated in 2018, we found evidence that the pooled effects for the two formats were equivalent in the treatment of psychiatric and somatic disorders, but the number of published randomized trials was relatively low (n=20). As this is a field that moves rapidly, the aim of the current study was to conduct an update of our systematic review and meta-analysis of the clinical effects of ICBT vs. face-to-face CBT for psychiatric and somatic disorders in adults. We searched the PubMed database for relevant studies published from 2016 to 2022. The main inclusion criteria were that studies had to compare ICBT to face-to-face CBT using a randomized controlled design and targeting adult populations. Quality assessment was made using the Cochrane risk of bias criteria (Version 1), and the main outcome estimate was the pooled standardized effect size (Hedges’ g) using a random effects model. We screened 5,601 records and included 11 new randomized trials, adding them to the 20 previously identified ones (total n=31). Sixteen different clinical conditions were targeted in the included studies. Half of the trials were in the fields of depression/depressive symptoms or some form of anxiety disorder. The pooled effect size across all disorders was g=0.02 (95% CI: –0.09 to 0.14) and the quality of the included studies was acceptable. This meta-analysis further supports the notion that therapist-supported ICBT yields similar effects as face-to-face CBT.     

Integrating evidence-based treatments for common mental disorders in routine primary care: feasibility and acceptability of the MANAS intervention in Goa,India

Common mental disorders, such as depression and anxiety, pose a major public health burden in developing countries. Although these disorders are thought to be best managed in primary care settings, there is a dearth of evidence about how this can be achieved in low resource settings. The MANAS project is an attempt to integrate an evidence based package of treatments into routine public and private primary care settings in Goa, India. Before initiating the trial, we carried out extensive preparatory work, over a period of 15 months, to examine the feasibility and acceptability of the planned intervention. This paper describes the systematic development and evaluation of the intervention through this preparatory phase. The preparatory stage, which was implemented in three phases, utilized quantitative and qualitative methods to inform our understanding of the potential problems and possible solutions in implementing the trial and led to critical modifications of the original intervention plan. Investing in systematic formative work prior to conducting expensive trials of the effectiveness of complex interventions is a useful exercise which potentially improves the likelihood of a positive result of such trials.     

Advantages and limitations of Internet‐based interventions for common mental disorders

Several Internet interventions have been developed and tested for common mental disorders, and the evidence to date shows that these treatments often result in similar outcomes as in face‐to‐face psychotherapy and that they are cost‐effective. In this paper, we first review the pros and cons of how participants in Internet treatment trials have been recruited. We then comment on the assessment procedures often involved in Internet interventions and conclude that, while online questionnaires yield robust results, diagnoses cannot be determined without any contact with the patient. We then review the role of the therapist and conclude that, although treatments including guidance seem to lead to better outcomes than unguided treatments, this guidance can be mainly practical and supportive rather than explicitly therapeutic in orientation. Then we briefly describe the advantages and disadvantages of treatments for mood and anxiety disorders and comment on ways to handle comorbidity often associated with these disorders. Finally we discuss challenges when disseminating Internet interventions. In conclusion, there is now a large body of evidence suggesting that Internet interventions work. Several research questions remain open, including how Internet interventions can be blended with traditional forms of care.     

Understanding the expanding role of primary care physicians (PCPs) to primary psychiatric care physicians (PPCPs): enhancing the assessment and treatment of psychiatric conditions

Aim In the current healthcare system primary care physicians (PCPs) have, in effect, become the primary psychiatric care physicians (PPCPs) for many of their patients. Being the PPCP in an already busy and stressful medical industry presents additional time management and treatment challenges to successfully manage patients' medical and psychiatric needs. The aim of the study was to ascertain PCPs' psychiatric assessment and treatment practices and to determine the extent to which PCPs have a need for using a structured psychiatric assessment tool.Method We sent 300 PCPs a survey to examine their psychiatric assessment and treatment practices. A one-page questionnaire was used to inquire about PCPs' psychiatric care practice habits including types of conditions treated, psychiatric medications prescribed, assessment methods used, interest in using a structured assessment tool and referral sources used. Sixty-eight usable surveys (23%) were returned.Results PCPs identify approximately one-third of their patients as mental health patients. They are treating a wide range of psychiatric conditions and prescribing a variety of psychiatric medications. The vast majority are using traditional clinical interviewing as their primary method of psychiatric assessment. However, the majority were willing to use a structured psychiatric assessment tool.Conclusion PCPs are serving a useful role in providing psychiatric treatment to many of their patients. Using a more structured psychiatric assessment method in practice could ultimately strengthen the assessment and treatment of psychiatric conditions in primary care settings.     

Screening for suicidal thoughts in primary care: the views of patients and general practitioners

Background It has been argued that primary care practitioners have an important part to play in the prevention of suicide. However, levels of assessment of risk of suicide among patients treated in this setting are generally low.Methods Cross-sectional survey of general practitioners (GPs) and people being treated in primary care who had signs of depression. The study combined open and closed questions on attitudes to screening or being screened for suicidal ideation.Results One hundred and one of 132 patients took part in the survey and 103 of 300 GPs completed a questionnaire. A majority of both GPs and patients stated that people should be screened for suicidal ideation. However, an important minority of patients and GPs stated that asking or being asked such questions made them feel uncomfortable. Less than half of GPs had received formal training on the assessment of suicide risk. GPs told the researchers that barriers to screening included time pressures, culture and language, and concerns about the impact that screening could have on people's mental health. One-quarter of GPs and one-fifth of patients supported the notion that screening for suicidal ideation could induce a person to have thoughts of self-harm.Conclusions GPs and family doctors should screen for suicidal risk among depressed patients and should receive training on how to do this as part of their general training in the assessment and management of mental disorders. Research should be conducted to examine what, if any, effect screening for suicidal ideation has on mental health.     

The microRNAs (miRs) overexpressing mesenchymal stem cells (MSCs) therapy in neurological disorders; hope or hype

Altered expression of multiple miRNAs was found to be extensively involved in the pathogenesis of different neurological disorders including Alzheimer's disease, Parkinson's disease, stroke, epilepsy, multiple sclerosis, amyotrophic lateral sclerosis, and Huntington's disease. One of the biggest concerns within gene-based therapy is the delivery of the therapeutic microRNAs to the intended place, which is obligated to surpass the biological barriers without undergoing degradation in the bloodstream or renal excretion. Hence, the delivery of modified and unmodified miRNA molecules using excellent vehicles is required. In this light, mesenchymal stem cells (MSCs) have attracted increasing attention. The MSCs can be genetically modified to express or overexpress a particular microRNA aimed with promote neurogenesis and neuroprotection. The current review has focused on the therapeutic capabilities of microRNAs-overexpressing MSCs to ameliorate functional deficits in neurological conditions.     

Guided Internet‐based vs. face‐to‐face cognitive behavior therapy for psychiatric and somatic disorders: a systematic review and meta‐analysis

Internet-delivered cognitive behavior therapy (ICBT) has been tested in many research trials, but to a lesser extent directly compared to face-to-face delivered cognitive behavior therapy (CBT). We conducted a systematic review and meta-analysis of trials in which guided ICBT was directly compared to face-to-face CBT. Studies on psychiatric and somatic conditions were included. Systematic searches resulted in 13 studies (total N=1053) that met all criteria and were included in the review. There were three studies on social anxiety disorder, three on panic disorder, two on depressive symptoms, two on body dissatisfaction, one on tinnitus, one on male sexual dysfunction, and one on spider phobia. Face-to-face CBT was either in the individual format (n=6) or in the group format (n=7). We also assessed quality and risk of bias. Results showed a pooled effect size (Hedges'' g) at post-treatment of −0.01 (95% CI: −0.13 to 0.12), indicating that guided ICBT and face-to-face treatment produce equivalent overall effects. Study quality did not affect outcomes. While the overall results indicate equivalence, there are still few studies for each psychiatric and somatic condition and many conditions for which guided ICBT has not been compared to face-to-face treatment. Thus, more research is needed to establish equivalence of the two treatment formats.     

Parental behaviour in Copris lunaris (Coleoptera, Scarabaeidae): care and defence of brood balls and nest

Abstract. 1. Nesting female beetles righted brood balls (so as to replace the egg or larva in the uppermost position) and repaired damaged balls. This behaviour required the presence of an egg or larva in the ball, or of a short-lasting material found just after oviposition. The shape of the ball was also a righting stimulus since artificial ellipsoids were stood on end.
2. Balls containing dichloromethane extracts of C.lunaris brood were righted and repaired. Eggs and larvae of several other Scarabaeidae did not release these responses but were destroyed.
3. Righting behaviour was released when brood was absent from the top of the ball. The beetle then crawled vertically downwards and, if it encountered the displaced apex, a novel rolling action followed which automatically turned the ball towards the correct position.
4. An opening made in the nest was repaired with soil excavated from the chamber floor. Clunaris adults and Aphodius fossor larvae were attacked if they were encountered in the nest.     

Effects of an educational outreach campaign (IMPACT) on depression management delivered to general practitioners in one primary care trust

Objective An educational outreach initiative with general practitioners (GPs) within Walsall, led by pharmacists and aimed at delivering evidence-based guidance on stepped care management of clinical depression.Methods Standardised educational material was produced with key messages and contributions by experts on prescribing principles and management of clinical depression based on NICE guidance. The primary care pharmacists together with a psychiatrist or other professional delivered the training through initial face-to-face meetings with GP practices and carrying out follow-up visits.Evaluation Analysis of prescribing data (PACT) on antidepressants, which included prescribing of defined daily doses (DDD) and net ingredient cost (NIC) of commonly prescribed antidepressants for the whole of Walsall teaching Primary Care Trust (tPCT) and comparison with prescribing data for the West Midlands and for England during the period June 2000 to June 2006.Results The use of Fluoxetine increased slightly and the prescribing of Dosulepin continued to fall. The prescribing of Escitalopram, which had steadily increased prior to the launch of campaign, showed decline, resulting in savings of over ￡50K in the year 2005 to 2006. This was in comparison to a relative increase in the prescribing for Escitalopram for the same time period in the West Midlands and nationally. Prescribing of Dosulepin continued to fall. The total cost of prescribing for the four antidepressants fell and theses changes were sustained over the following year.Conclusions The educational outreach campaign successfully influenced prescribing behaviour in terms of adhering to NICE guidance and cost-effective prescribing, and also facilitated improved communication among clinicians at the primary-secondary care interface.     

On the use of AAA and AcurosXB algorithms for three different stereotactic ablative body radiotherapy (SABR) techniques: Volumetric modulated arc therapy (VMAT), intensity modulated radiation therapy (IMRT) and 3D conformal radiotherapy (3D-CRT)

AimThe purpose of this study was to investigate the dosimetric characteristics of three stereotactic ablative body radiotherapy (SABR) techniques using the anisotropic analytical algorithm (AAA) and Acuros XB algorithm. The SABR techniques include coplanar volumetric modulated arc therapy (C-VMAT), non-coplanar intensity modulated radiation therapy (NC-IMRT) and non-coplanar three-dimensional conformal radiotherapy (NC-3D CRT).BackgroundSABR is a special type of radiotherapy where a high dose of radiation is delivered over a short time. The treatment outcome and accuracy of the dose delivered to cancer patients highly depend on the dose calculation algorithm and treatment technique.Materials and methodsTwelve lung cancer patients underwent 4D CT scanning, and three different treatment plans were generated: C-VMAT, NC-IMRT, NC-3D CRT. Dose calculation was performed using the AAA and Acuros XB algorithm. The dosimetric indices, such as conformity index (CI), homogeneity index, dose fall-off index, doses received by organs at risk and planning target volume, were used to compare the plans. The accuracy of AAA and Acuros XB (AXB) algorithms for the lung was validated against measured dose on a CIRS thorax phantom.ResultsThe CIs for C-VMAT, NC-IMRT and NC-3D CRT were 1.21, 1.28 and 1.38 for the AAA, respectively, and 1.17, 1.26 and 1.36 for the Acuros XB algorithm, respectively. The overall dose computed by AcurosXB algorithm was close to the measured dose when compared to the AAA algorithm. The overall dose computed by the AcurosXB algorithm was close to the measured dose when compared to the AAA algorithm.ConclusionThis study showed that the treatment planning results obtained using the Acuros XB algorithm was better than those using the AAA algorithm in SABR lung radiotherapy.     

Investigating mental health risk assessment in primary care and the potential role of a structured decision support tool,GRiST

Aim To explore current risk assessment processes in general practice and Improving Access to Psychological Therapies (IAPT) services, and to consider whether the Galatean Risk and Safety Tool (GRiST) can help support improved patient care.Background Much has been written about risk assessment practice in secondary mental health care, but little is known about how it is undertaken at the beginning of patients'' care pathways, within general practice and IAPT services.Methods Interviews with eight general practice and eight IAPT clinicians from two primary care trusts in the West Midlands, UK, and eight service users from the same region. Interviews explored current practice and participants'' views and experiences of mental health risk assessment. Two focus groups were also carried out, one with general practice and one with IAPT clinicians, to review interview findings and to elicit views about GRiST from a demonstration of its functionality. Data were analysed using thematic analysis.Findings Variable approaches to mental health risk assessment were observed. Clinicians were anxious that important risk information was being missed, and risk communication was undermined. Patients felt uninvolved in the process, and both clinicians and patients expressed anxiety about risk assessment skills. Clinicians were positive about the potential for GRiST to provide solutions to these problems.Conclusions A more structured and systematic approach to risk assessment in general practice and IAPT services is needed, to ensure important risk information is captured and communicated across the care pathway. GRiST has the functionality to support this aspect of practice.     

The evolution of parental behaviour in Scarabaeinae (Coleoptera, Scarabaeidae): an experimental approach

ABSTRACT.

• 1 Dung beetle lifestyles are reviewed. Most Scarabaeinae lay their eggs in dung masses that are packed into underground chambers, but Coprini and Scarabaeini typically lay their eggs in free-standing brood balls and it is in these tribes that parental care of the brood has evolved.
• 2 Brood balls are constructed by aggregating fragments of dung. This technique is derived from the method of gathering dung at the surface. Larvae developing in brood balls are better protected against dehydration and parasite attack. The repair technique of Scarabaeine larvae preadapts them to life in brood balls.
• 3 Parental care by Copris lunaris depends on appropriate responses by the female to the brood, and it has the selective advantage of protecting the brood against parasites. Preadaptations for parental care in‘non-brooding’Coprini are discussed.
• 4 Variations in the basic Copris nesting behaviour are summarized. Similar variations can occur spontaneously in C.lunaris and can also be released by unusual circumstances.
• 5 C.lunaris females could in principle cooperate but certain factors have prevented this social evolution. The significance of the transient cooperation with the male beetle is discussed.

     

All in for mental health: a pilot study of group therapy for people experiencing anxiety and/or depression and a significant other of their choice

Background A need to provide treatment for people with anxiety and/or depression, and to provide preventive strategies for individuals who love them has been identified. In response, an innovative group therapy programme for people with anxiety and/or depression and a significant other of their choice was developed and implemented.Methods Mixed methods were employed. Five 'significant other' groups were held between May 2005 and June 2006. All group participants were requested to complete the Depression Anxiety Stress Scale (DASS), World Health Organization Quality of Life Assessment (WHOQol) and Connor-Davidson Resilience Scale (CD-RISC), pre- and post-therapy, and three months after their last therapy session. In addition, participants who attended groups between July and September 2005 were invited to provide feedback about the group therapy in an individual semi-structured interview.Results Pilot results indicate positive responses from clients, related to facilitation of knowledge and understanding and skills development. For people referred to the group significant improvements were found in the DASS scores, resilience, psychological health and living environment.Limitations Due to the small sample size, and lack of follow-up data and control group, the findings need to be considered with caution and indicate the necessity to collect further data to provide conclusive findings.Conclusions Overall, the outcome of the 'significant other' pilot programme was useful, in that it facilitated a number of positive outcomes for participants. Areas for further research have been identified including strategies to improve social relationships, the de-identification with the sick/supporter role, and testing this model with diverse populations and clinical groups.     

A randomized controlled effectiveness trial of cognitive behavior therapy for post-traumatic stress disorder in terrorist-affected people in Thailand

Although cognitive behaviour therapy (CBT) is the treatment of choice for post-traumatic stress disorder (PTSD), there is no evidence of its success with PTSD patients still under direct threat of terrorist attacks. This study reports the first randomized controlled trial of CBT for PTSD terrorist-affected people. Twenty-eight survivors of terrorist attacks in southern Thailand were randomized to 8 sessions of either CBT or treatment as usual (TAU). CBT was modified to accommodate the realistic threats facing patients. There were independent assessments conducted before, immediately after, and 3 months following treatment. Main outcome measures included symptoms of PTSD (PTSD Symptom Scale Interview), depression (Beck Depression Inventory) and complicated grief (Inventory of Complicated Grief). CBT resulted in significantly greater reduction in symptoms, including PTSD, depression, and complicated grief, at follow-up than TAU. Relative to TAU, CBT had stronger effect sizes at follow-up for PTSD, depression, and complicated grief. More patients in the CBT condition (75%) achieved high end-state functioning than participants in the TAU (33%). This preliminary evidence suggests that PTSD, depression, and complicated grief can be effectively treated despite ongoing threats of terrorism. Further, it demonstrates that non-specialist mental health workers in a non-western setting can be efficiently trained in using CBT, and this training can translate into successful treatment gains in trauma-affected individuals.     

Subsocial behaviour in Oniticellus cinctus (Coleoptera, Scarabaeidae): effect of the brood on parental care and oviposition

ABSTRACT. In Oniticellus cinctus (F.) the nest chambers each contain about twenty brood balls. Females enlarge the brood balls during the egg and larval stages and remain in the chamber for the whole period of brood development (1 month); they then make a new nest after 1 week. The presence of the brood releases parental care and ensures that the mother remains in the nest: she repairs defects in the brood balls and the nest, and expels other O. cinctus females. A new ball is formed around a naked O. cinctus larva, but larvae of other species are killed. In addition, the brood inhibits oviposition: removal (or addition) of brood balls stimulates (or inhibits) egg laying. In inhibited ovarioles, existing follicles are resorbed and production of new ones ceases. Control of clutch size by the brood is an adaptation to the nest structure and life history of O. cinctus. It may have an important role in the reproductive strategy of other insects with parental care.     

Effects of cognitive challenge on self-directed behaviors by chimpanzees (Pan troglodytes)

In primates, including humans, scratching and other self-directed behaviors (SDBs) have recently been reported to be differentially displayed as a function of social interactions, anxiety-related drugs, and response outcomes during learning tasks. Yet few studies have focused on the factors influencing SDBs in our closest living relatives, the chimpanzees (Pan troglodytes). Furthermore, no previous experimental study has examined handedness of SDBs as a function of changes in task difficulty. Using matching-to-sample tasks of varying difficulty, the present study examines the effect of manipulations of task difficulty on rates, handedness, and type of SDBs in an experimental study of eight chimpanzees. SDBs were categorized as rubs, gentle scratches, and rough scratches. SDBs increased during difficult discriminations, but only for subjects who started the experiment on an easy discrimination; subjects who started on a difficult discrimination exhibited no differential rates of SDBs as a function of task difficulty. There was a tendency to exhibit relatively more SDBs with the right hand in the more difficult task. Rates of SDBs decreased after auditory feedback signals, suggesting a link between SDBs and uncertainty. Rubs were directed more to the face (trigeminal), and gentle and rough scratches more to the body (spinothalamic), suggesting that face-directed SDBs may index a different motivational basis than scratches. Taken together, these results extend previous research on SDBs to the domain of cognitive stress in nonsocial contexts, demonstrating that SDBs are sensitive to manipulations of task difficulty in chimpanzees.