Search

Introduction At least one in four people treated by the primary care improving access to psychological therapies (IAPT) programme in England experiences distressing psychotic experiences (PE) in addition to common mental disorder (CMD). These individuals are less likely to achieve recovery. IAPT services do not routinely screen for nor offer specific treatments for CMD including PE. The Tailoring evidence-based psychological therapY for People with common mental disorder including Psychotic EXperiences study will evaluate the clinical and cost-effectiveness of an enhanced training for cognitive behavioural therapists that aims to address this clinical gap.Methods and analysis This is a multisite, stepped-wedge cluster randomised controlled trial. The setting will be IAPT services within three mental health trusts. The participants will be (1) 56–80 qualified IAPT cognitive behavioural therapists and (2) 600 service users who are triaged as appropriate for cognitive behavioural therapy in an IAPT service and have PE according to the Community Assessment of Psychic Experiences—Positive 15-items Scale. IAPT therapists will be grouped into eight study clusters subsequently randomised to the control-intervention sequence. We will obtain pseudonymous clinical outcome data from IAPT clinical records for eligible service users. We will invite service users to complete health economic measures at baseline, 3, 6, 9 and 12-month follow-up. The primary outcome will be the proportion of patients with common mental disorder psychotic experiences who have recovered by the end of treatment as measured by the official IAPT measure for recovery.Ethics and dissemination The study received the following approvals: South Central—Berkshire Research Ethics Committee on 28 April 2020 (REC reference 20/SC/0135) and Health Research Authority (HRA) on 23 June 2020. An amendment was approved by the Ethics Committee on 01 October 2020 and HRA on 27 October 2020. Results will be made available to patients and the public, the funders, stakeholders in the IAPT services and other researchers.Trial registration number ISRCTN93895792.

Abstract Background Over the last few decades, effective psychological treatments for posttraumatic stress disorder (PTSD) have been developed, but many patients are currently unable to access these treatments. There is initial evidence that therapist-assisted internet-based psychological treatments are effective for PTSD and may help increase access, but it remains unclear which of these treatments work best and are most acceptable to patients. This randomised controlled trial will compare a trauma-focussed and a nontrauma-focussed therapist-assisted cognitive behavioural Internet treatment for PTSD: Internet-delivered cognitive therapy for PTSD (iCT-PTSD) and internet-delivered stress management therapy (iStress-PTSD). Methods/design The study is a single-blind, randomised controlled trial comparing iCT-PTSD, iStress-PTSD and a 13-week wait-list condition, with an embedded process study. Assessors of treatment outcome will be blinded to trial arm. Two hundred and seventeen participants who meet DSM-5 criteria for PTSD will be randomly allocated by a computer programme to iCT-PTSD, iStress-PTSD or wait-list at a 3:3:1 ratio. The primary assessment point is at 13 weeks, and further assessments are taken at 6, 26, 39 and 65 weeks. The primary outcome measure is the severity of PTSD symptoms as measured by the PTSD Checklist for DSM-5 (PCL-5). Secondary measures of PTSD symptoms are the Clinician Administered PTSD Scale for DSM-5 (CAPS-5) and the Impact of Event Scale-Revised (IES-R). Other symptoms and well-being will be assessed with the Patient Health Questionnaire (PHQ-9), Generalised Anxiety Disorder Scale (GAD-7), WHO (Five) Well-Being Index, Work and Social Adjustment Scale (WSAS), Endicott Quality of Life Scale (QoL), and Insomnia Sleep Index (ISI). Health economics analyses will consider quality of life, productivity, health resource utilisation, employment status and state benefits, and treatment delivery costs. Process analyses will investigate candidate mediators and moderators of outcome. Patient experience will be assessed by interview and questionnaire. Discussion This study will be the first to compare the efficacy of a trauma-focussed and nontrauma-focussed therapist-assisted online cognitive behavioural treatment for people with posttraumatic stress disorder. Trial registration ISRCTN16806208 . Registered prospectively on 5 January 2018.

Abstract Background Many people who have common mental disorders, such as depression and anxiety, also have some psychotic experiences. These experiences are associated with higher clinical complexity, poor treatment response, and negative clinical outcomes. Psychological interventions have the potential to improve outcomes for people with psychotic experiences. The aims of this systematic review are to (1) synthesise the evidence on the effectiveness and cost-effectiveness of psychological interventions to reduce psychotic experiences and their associated distress and (2) identify key components of effective interventions. Methods Our search strategy will combine terms for (1) psychological interventions, (2) psychotic experiences, and (3) symptoms associated with psychotic experiences. We will search the following online databases: MEDLINE, Embase, PsycINFO, all Cochrane databases, British Nursing Index (BNI), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Health Management Information Consortium (HMIC), Education Resources Information Center (ERIC), and EconLit. Our primary outcome is the proportion of people who recovered or remitted from psychotic experiences after the intervention. Our secondary outcomes are changes in positive psychotic symptoms, negative psychotic symptoms, depression, anxiety, functioning (including social, occupational, and academic), quality of life, and cost-effectiveness. Two independent reviewers will judge each study against pre-specified inclusion and exclusion criteria and will extract study characteristics, outcome data, and intervention components. Risk of bias and methodological quality will be assessed using the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies and the Drummond Checklist. Results will be synthesised using random-effects meta-analysis and narrative synthesis. Discussion The identification of effective psychological interventions and of specific components associated with intervention effectiveness will augment existing evidence that can inform the development of a new, tailored intervention to improve outcomes related to psychotic symptoms, anxiety and depression, distress, functioning, and quality of life. Systematic review registration PROSPERO CRD42016033869

Background: Working alliance has been shown to predict outcome of psychological treatments in multiple studies. Conversely, changes in outcome scores have also been found to predict working alliance ratings.Objective: To assess the temporal relationships between working alliance and outcome in 230 patients receiving trauma-focused cognitive behavioral treatment for posttraumatic stress disorder (PTSD).Methods: Ratings of working alliance were made by both the patient and therapist after sessions 1, 3, and 5 of a course of Cognitive Therapy for PTSD (CT-PTSD). Autoregressive, cross-lagged panel models were used to examine whether working alliance predicted PTSD symptom severity at the next assessment point and vice versa. Linear regressions tested the relationship between alliance and treatment outcome.Results: Both patients' and therapists' working alliance ratings after session 1 predicted PTSD symptom scores at the end of treatment, controlling for baseline scores. At each assessment point, higher therapist working alliance was associated with lower PTSD symptoms. Crossed-lagged associations were found for therapist-rated alliance, but not for patient-rated alliance: higher therapists' alliance ratings predicted lower PTSD symptom scores at the next assessment point. Similarly, lower PTSD symptoms predicted higher therapist working alliance ratings at the next assessment point. Ruminative thinking was negatively related to therapists' alliance ratings.Conclusions: Working alliance at the start of treatment predicted treatment outcome in patients receiving CT-PTSD and may be an important factor in setting the necessary conditions for effective treatment. For therapists, there was a reciprocal relationship between working alliance and PTSD symptom change in their patients during treatment, suggesting that their alliance ratings predicted symptom change, but were also influenced by patients' symptom change.

Background: Numerous studies have shown that trauma-focused psychological treatments for PTSD are effective (Lewis, Roberts, Andrew, Starling, & Bisson, ). Few studies to date have investigated the processes of change during treatment. There is initial evidence that these treatments change problematic beliefs about the trauma and its consequences, and that belief change drives symptom change (Brown, Belli, Asnaani, & Foa, ). Further studies of other candidate processes are needed. Objective: To investigate the temporal relationships between changes in theory-derived (Ehlers & Clark, ) treatment specific processes (appraisals, trauma memory characteristics, and unhelpful cognitive and behavioural responses) and non-specific processes (working alliance) and symptom change during a course of cognitive therapy for PTSD (e.g. Wild et al., ). Study 1 Methods: Session by session changes in self-reports of cognitive factors and PTSD symptoms obtained from patients treated in routine clinical care were analysed with bivariate latent change score models (LCSM). Results: Were preceded by changes in for most measures, changes in cognitive factors preceded changes in PTSD symptoms, but not vice versa. Study 2 Methods: Patient and therapist ratings of working alliance were taken repeatedly. Autoregressive, cross-lagged models were used to examine whether working alliance predicted PTSD symptom severity at the next assessment point and vice versa. Results: Higher patient and therapist working alliance was associated with lower PTSD symptoms. Crossed-lagged associations were found for therapist-rated alliance, but not for patient-rated alliance. A better working alliance at the start of treatment predicted treatment outcome. For most measures, changes in cognitive factors preceded changes in PTSD symptoms, but not vice versa. Conclusions: Study 1 extended previous findings that that cognitive and behavioural processes suggested by theoretical models of PTSD play a key role in driving symptom improvement during trauma-focused CBT. Changes in cognitive factors preceded symptom change. This result suggests that monitoring these processes during therapy may help therapist in maximising treatment outcomes in individual patients, and may also point to further ways of optimising treatments in general. Study 2 suggested that working alliance may be an important factor in setting the necessary conditions for effective treatment, but did not find evidence of a temporal precedence of changes in working alliance driving symptom change.

Delivering trauma-focused cognitive behavioural therapy to patients with PTSD during the COVID-19 pandemic poses challenges. The therapist cannot meet with the patient in person to guide them through trauma-focused work and other treatment components, and patients are restricted in carrying out treatment-related activities and behavioural experiments that involve contact with other people. Whilst online trauma-focused CBT treatments for PTSD have been developed, which overcome some of these barriers in that they can be delivered remotely, they are not yet routinely available in clinical services in countries, such as the UK. Cognitive therapy for PTSD (CT-PTSD) is a trauma-focused cognitive behavioural therapy that is acceptable to patients, leads to high rates of recovery and is recommended as a first-line treatment for the disorder by international clinical practice guidelines. Here we describe how to deliver CT-PTSD remotely so that patients presenting with PTSD during the COVID-19 pandemic can still benefit from this evidence-based treatment.

An improved ability to predict pasture dry matter (DM) yield response to applied nitrogen (N) is a crucial step in determining the production and economic benefits of N fertiliser inputs with associated environmental benefits from reducing inefficient N fertiliser use. Pasture DM yield responses to applied N fertiliser from 920 independent field trial sites were used from a database repository of Australian fertiliser experiments. These data were analysed and a quantitative non-linear mixed-effects model based on the Mitscherlich function was developed. The fitted model provided a good fit to a large body of data ([R.sup.2] = 0.92), using readily interpretable coefficients, including fixed effects for state by season, phosphorus status and harvest type (initial or residual), and nested random effects for location and trial or subtrial. The model was limited by patchiness of metadata, uneven representation of regions and few very high rates of applied N in the data. Nonetheless, model predictions were comparable with independent spring pasture DM responses to applied N fertiliser from subsequent field studies on three contrasting pastures on commercial dairy farms in Victoria. The final derived model can be used to predict pasture yield response to applied N fertiliser as a proportion of obtainable yield and can be scaled to absolute response using the fitted model estimates of maximal yield or, more usefully, a specified maximal yield by the user. Importantly, the response function exhibits diminishing returns, enabling marginal economic analysis and determination of optimum N fertiliser application rate to a specified pasture. Additional keywords: Mitscherlich response function, pasture growth, rate response, urea., Introduction Inorganic fertiliser has become the dominant nitrogen (N) input in both cropping and intensive grazing systems globally (Galloway et al. 2017). The application of N fertiliser on pastures is [...]

Large N surpluses are a feature of most dairy farms worldwide. Despite the predominance of grazing systems in Australia, increasing animal densities and greater reliance on purchased feed mean that feed nutrient inputs and the role of grazing animals in N flows and deposited loads have grown. However, quantifying nutrient intakes and N excretion is difficult on commercial farms due to challenges in estimating pasture dry matter (DM) intake by grazing cattle. The aim of the present study was to quantify for commercial dairy farms, N excreted by lactating herds, the relative amounts of excreta N versus farm N inputs, and N loads deposited to different within-farm locations. Data were collected on at least five occasions from 43 diverse grazing system farms located in different climatic zones. An animal performance method for estimating annual DM intake was modified to calculate daily N intake and excretion and animal feed N use efficiency (NUE; milk N secreted/feed N intake). On average, these herds received 52% of their energy requirements from supplementary feeds despite the grazing base. Mean N intake (545 g [cow.sup.-1] [day.sup.-1]), which greatly exceeded recommended dietary intakes, resulted in mean excretion of 433 g N [cow.sup.-1] [day.sup.-1] and low mean NUE (21%; range 1139%). Calculated annual N flows through the lactating herds were equivalent to 69% of total N inputs onto these farms. When excreted N was apportioned to the locations visited by the lactating herds, deposition to pasture paddocks was not uniform. Almost 50% more excreted N was deposited to paddocks that were closer to the dairy shed, and approximately twice as much N was returned to feedpads and holding areas as deposited in dairy sheds and yards, with the potential for N accumulation and loss in these places. On average, 20% more N was deposited as excreta on pasture paddocks by the lactating herd than was applied as commercial fertiliser (168 vs 141 kg N [ha.sup.-1] respectively). These results demonstrate that quantifying excreta N loads and spatial nutrient distribution by lactating cows can assist in improving N management in grazing system dairy farms. Additional keywords: animal performance, dietary crude protein, exercise or standing yards, feed use efficiency, metabolisable energy, nutrient loss, spatial nutrient distribution., Introduction Global N use continues to increase to meet the food demands of an expanding world population. For example, recent reports show that synthetic N fertiliser use has grown from [...]