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Abstract Background Cognitive impairment is common in haemodialysis patients with no known beneficial interventions. Cooler dialysate slows brain white-matter changes, but its effect on cognition is unknown. This feasibility trial was performed to inform a fully-powered, randomised trial to assess this. Methods We aimed to randomise (1:1) 90 haemodialysis patients to this double-blinded, randomised controlled feasibility trial to standard care (dialysate-temperature 36.5 °C) or intervention (35 °C). Eligible patients were adult chronic haemodialysis recipients with no established diagnosis of dementia or psychiatric disease. The primary outcome was change in Montreal Cognitive Assessment (MoCA) score at 12-months. Secondary outcomes included recruitment and attrition rates, reasons for non-recruitment, intradialytic hypotension, depression, patient burden, computerised cognition test battery, and quality of life. Findings Of 334 patients screened, 160 were eligible. 99 declined mainly for the extra non-dialysis day study visits. Sixty-one patients consented, 43 randomised – 20 in standard care, 23 in intervention arms; 13 withdrew for non-dialysis day visits and 5 without reason before randomisation. 27 patients (12 standard care, 15 intervention) completed the trial – 5 died, 1 transplanted, 4 withdrew consent, and 6 could not attend due to the pandemic. Low temperature dialysis was well tolerated. There was no difference in change in MoCA from baseline to 12 months between the standard and intervention arms; 1.0 (-2.8–3.0, p = 0.755) and − 2.0 (-1.0 - -4.0, p = 0.047) respectively. There were no differences between groups on any secondary measures. There were no significant adverse events reported. Discussion The trial was significantly affected by the COVID-19 pandemic contributing to an attrition rate of 27%. The non-dialysis day research visits were mainly responsible for low recruitment and consent withdrawal. There are several learning points, described in the article, which will inform design of definitive trials in this area in the future. Trial registration ClinicalTrials.gov Identifier NCT03645733. Registration date 24/08/2018.

Abstract Background Mood disorders, including unipolar and bipolar depression, contribute significantly to the global burden of disease. Psychological therapy is considered a gold standard non-pharmacological treatment for managing these conditions; however, a growing body of evidence also supports the use of lifestyle therapies for these conditions. Despite some clinical guidelines endorsing the application of lifestyle therapies as a first-line treatment for individuals with mood disorders, there is limited evidence that this recommendation has been widely adopted into routine practice. A key obstacle is the insufficient evidence on whether lifestyle therapies match the clinical and cost effectiveness of psychological therapy, particularly for treating those with moderate to severe symptoms. The HARMON-E Trial seeks to address this gap by conducting a non-inferiority trial evaluating whether a multi-component lifestyle therapy program is non-inferior to psychological therapy on clinical and cost-effectiveness outcomes over 8-weeks for adults with major depressive disorder and bipolar affective disorder. Methods This trial uses an individually randomised group treatment design with computer generated block randomisation (1:1). Three hundred and seventy-eight adults with clinical depression or bipolar affective disorder, a recent major depressive episode, and moderate-to-severe depressive symptoms are randomised to receive either lifestyle therapy or psychological therapy (adjunctive to any existing treatments, including pharmacotherapies). Both therapy programs are delivered remotely, via a secure online video conferencing platform. The programs comprise an individual session and six subsequent group-based sessions over 8-weeks. All program aspects (e.g. session duration, time of day, and communications between participants and facilitators) are matched except for the content and program facilitators. Lifestyle therapy is provided by a dietitian and exercise physiologist focusing on four pillars of lifestyle (diet, physical activity, sleep, and substance use), and the psychological therapy program is provided by two psychologists using a cognitive behavioural therapy approach. Data collection occurs at baseline, 8-weeks, 16-weeks, and 6 months with research assistants blinded to allocation. The primary outcome is depressive symptoms at 8 weeks, measured using the Montgomery-Åsberg Depression Rating Scale (MADRS) (minimal clinically important difference = 1.6). A pre-specified within-trial economic evaluation will also be conducted. Discussion Should lifestyle therapy be found to be as clinically and cost effective as psychological therapy for managing mood disorders, this approach has potential to be considered as an adjunctive treatment for those with moderate to severe depressive symptoms. Trial registration Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12622001026718, registered 22nd July 2022. Protocol version: 4.14, 26/06/2024

BackgroundVirtual reality (VR) has been proposed as a technology to support mindfulness practice through promoting increased engagement and presence. The proposed benefits of this technology have been largely unexamined with clinical populations. Further research is required to understand its clinical potential and utility in improving and managing mental health symptoms. ObjectiveThis study aims to investigate the proximal impacts of a single, brief, VR-supported mindfulness practice for individuals with a mood or anxiety disorder and to understand user experiences, which may affect the acceptability and efficacy of VR mindfulness for this population. MethodsThis mixed methods study recruited 28 participants with a primary diagnosis of major depressive disorder, bipolar disorder, or anxiety disorder. Participants completed a mindfulness practice wearing a VR headset that was presenting an omnidirectional video of a forest scene, which was overlaid with a guided audio voiceover. Before and after the practice, measures were completed assessing state mindfulness (Toronto Mindfulness Scale), affect (Positive and Negative Affect Schedule), and anxiety (State-Trait Anxiety Inventory Y-1; n=27). Semistructured interviews were then held inquiring about the user experience and were analyzed using thematic analysis (n=24). ResultsAfter completing the VR-supported mindfulness practice, both measures of state mindfulness on the Toronto Mindfulness Scale, mean curiosity and decentering, increased significantly (Cohen d=1.3 and 1.51, respectively; P

Delusions are one of the core symptoms of schizophrenia spectrum disorders (SSD), associated with distress and impaired functioning. Traditional Cognitive Behavioral Therapy (CBT) approaches are less effective for delusions, require significant resources, and specialized staff training. Symptom-specific therapy approaches, which target factors involved in the development and maintenance of psychotic symptoms, provide a valid alternative. Recent research demonstrates the efficacy of coping strategies as an intervention element, however, so far, only in the context of auditory hallucinations. Digital technologies, such as ecological momentary assessment (EMA) and ecological momentary intervention (EMI), are gaining attention in mental health, providing enhanced assessment and intervention opportunities. The present single-arm trial aimed to investigate the feasibility, acceptability, and preliminary outcomes of a smartphone-based blended EMA/I psychological therapy approach focusing on improving coping strategies for delusions in SSD. In total, N = 10 participants received four face-to-face therapy sessions alongside German university-level treatment-as-usual over an intervention period of four to six weeks. Feasibility was assessed by completion rates of the EMA/I questionnaires, use of the application between sessions and recruitment rates. Acceptability was assessed by a satisfaction questionnaire, open feedback, and analysis of adverse effects. Clinical outcomes included self-rated and rater-based intensity and distress of delusions and comorbid symptoms at pre- and post-intervention. Findings supported the feasibility and acceptability of the DICE (DICE - Delusion Ideation in the Context of Everyday life intervention) intervention, with high retention (10/13 participants, 77 %) and completion rates for the EMA- (59 %) and EMI-questionnaires (72 %), as well as a high protocol adherence (90–97 %), exceeding all predefined benchmarks. Open feedback indicated good satisfaction, with all participants using the application between sessions, reflecting a high engagement level. Clinical outcomes displayed relevant changes in ameliorating the intensity of delusions when being measured by the Psychotic Symptom Rating Scales as well as by the Green Paranoid Thought Scale, and self-rated improvements in distress and depressive symptoms. Changes in the intensity and distress of delusions might be explained by improved coping behaviour. Further research with control conditions is needed to validate findings and analyze the efficacy as well as mechanisms of actions of the intervention in a fully powered trial.

Digital Mental Health Technologies (DMHTs) have the potential to close treatment gaps in settings where mental healthcare is scarce or even inaccessible. For this, DMHTs need to be affordable, evidence-based, justice-oriented, user-friendly, and embedded in a functioning digital infrastructure. This viewpoint discusses areas crucial for future developments of DMHTs. Drawing back on interdisciplinary scholarship, questions of health equity, consumer-, patient- and developer-oriented legislation, and requirements for successful implementation of technologies across the globe are discussed. Economic considerations and policy implications complement these aspects. We discuss the need for cultural adaptation specific to the context of use and point to several benefits as well as pitfalls of DMHTs for research and healthcare provision. Nonetheless, to circumvent technology-driven solutionism, the development and implementation of DMHTs require a holistic, multi-sectoral, and participatory approach.

Body Dysmorphic Disorder (BDD) is characterized by an intense preoccupation with one or more perceived “defects” in physical appearance. Despite the distress and impairment associated with BDD, the disorder remains understudied and poorly understood. In particular, there are limited studies available which give voice to those with firsthand experiences of the disorder. A qualitative approach was employed to study lived experience of BDD. In-depth semi-structured interviews were conducted with 12 participants with BDD, aiming to understand their subjective experiences of the disorder. Data was analyzed using Interpretative Phenomenological Analysis (IPA). The results identified three superordinate themes; (1) consumed by the disorder, (2) the flawed self, and (3) intolerance of uncertainty about appearance. The qualitative findings of this study are discussed in relation to current conceptual understandings of BDD, including the cognitive behavioral model.

BackgroundMany individuals living with dementia want to live in their own homes for as long as possible. To do so, they frequently require assistance with activities of daily living, which is often provided by friends and relatives acting as informal care partners. In Canada, many informal care partners are currently overworked and overwhelmed. Although community-based dementia-inclusive resources are available to support them, care partners often struggle to find them. Dementia613.ca was created to make the process of finding community dementia-inclusive resources simpler and more straightforward by bringing them together in one eHealth website. ObjectiveThe objective of our study was to determine if dementia613.ca is meeting the goal of connecting care partners and persons living with dementia to dementia-inclusive resources in their community. MethodsA review and assessment of the website was conducted using 3 evaluation methods: web analytics, questionnaires, and task analysis. Google Analytics was used to collect data related to website use over a 9-month period. Data on site content and user characteristics were collected. Furthermore, 2 web-based self-administered questionnaires were developed: one intended for care partners and persons living with dementia, and the other intended for businesses and organizations interested in serving persons living with dementia. Both gathered data on user characteristics and included standard questions used in website evaluations. Responses were collected over a 6-month period. Scenarios, tasks, and questions were developed for the moderated, remote, and task-analysis sessions. These tasks and questions determined how effectively persons living with dementia and their care partners can use dementia613.ca. Overall, 5 sessions were held with persons experiencing moderate cognitive decline and with care partners of persons living with dementia. ResultsThis evaluation showed that the idea behind dementia613.ca is strong and appeals to persons living with dementia, their care partners, and the businesses and organizations serving this market. Participants indicated that it is a useful community resource that meets a previously unfulfilled need in the area, and highlighted the benefits of bringing community resources together on 1 website. In our questionnaire, >60% (19/29, 66%) of people living with dementia and their care partners and 70% (7/10) of businesses and organizations agreed that the website made it easier to find relevant dementia-inclusive resources. There is room for improvement; participants indicated that the navigation and search features could be further developed. ConclusionsWe believe that the dementia613.ca model could be used to inspire and guide the creation of dementia resource websites in other regions in Ontario and beyond. The framework behind it is generalizable and could be replicated to help care partners and persons living with dementia find local resources more easily.

In the last decades, third wave approaches in cognitive-behavioral therapies (CBT) have shown effectiveness in treating several mental disorders, including schizophrenia spectrum disorders (SSD). Three crucial processes associated with clinical changes in patients include mindfulness, psychological flexibility (PF) and self-compassion (SC). PF is generally assessed by cognitive fusion (CF), a negative formulated key process of PF. The current study encompasses a cross-sectional design to examine the interplay of mindfulness, CF, SC and symptom severity in SSD. It was hypothesized that mindfulness is negatively correlated with symptom severity, CF mediates the negative relation between mindfulness and symptom severity, and SC moderates the link between mindfulness and CF. In total, 79 persons with SSD were recruited at the Department of Psychiatry and Neurosciences at the Charité – Universitätsmedizin Berlin. Correlations, as well as moderated mediation analyses, were performed using the analysis modeling tool PROCESS with total symptom severity and negative symptom severity as outcome variables, measured by the Positive and Negative Syndrome Scale (PANSS) and the Self-Evaluation of Negative Symptoms Scale (SNS). Results show that the moderated mediation hypothesis was confirmed for negative symptom severity assessed by SNS, however, not for total symptom severity assessed by PANSS. In general, the association between mindfulness and CF was stronger for participants with higher SC scores in our data. Future studies should investigate the relationship between mindfulness, SC, and PF regarding symptom severity in SSD in longitudinal designs while considering the impact on different outcomes and differences regarding assessment tools.

AimWe aimed to compare the mortality of individuals at low, moderate, and high risk of diabetic foot disease (DFD) in the context of newly diagnosed type 2 diabetes, before developing active diabetic foot problem.MethodsThis was a population-based cohort study of adults with newly diagnosed type 2 diabetes utilizing IQVIA Medical Research Data. The outcome was all-cause mortality among individuals with low, moderate, and high risk of DFD, and also in those with no record of foot assessment and those who declined foot examination.ResultsOf 225,787 individuals with newly diagnosed type 2 diabetes, 34,061 (15.1%) died during the study period from January 1, 2000 to December 31, 2019. Moderate risk and high risk of DFD were associated with increased mortality risk compared to low risk of DFD (adjusted hazard ratio [aHR] 1.50, 95% CI 1.42, 1.58; aHR 2.01, 95% CI 1.84, 2.20, respectively). Individuals who declined foot examination or who had no record also had increased mortality risk of 75% and 25% vs. those at low risk of DFD, respectively (aHR 1.75, 95% CI 1.51, 2.04; aHR 1.25, 95% CI 1.20, 1.30).ConclusionIndividuals with new-onset type 2 diabetes who had moderate to high risk of DFD were more likely to die compared to those at low risk of DFD. The associations between declined foot examination and absence of foot examinations, and increased risk of mortality further highlight the importance of assessing foot risk as it identifies not only patients at risk of diabetic foot ulceration but also mortality.

The structural characteristics of diatom cell walls (frustules) has led to their widespread use in diverse biotechnological applications, some of which can be further improved by surface chemical modification (functionalization). The use of coating agents can significantly increase surface binding capacity for target compounds. Frustules of the diatom Staurosirella pinnata used here were a by-product after applying a cascade-extraction process (for other products) to mass cultures. The protocol for the cleaning and functionalization of raw frustules using 3-Mercaptopropyl-trimethoxysilane and 3-Aminopropyl-trimethoxysilane was optimized and reported. Functionalization efficacy was observed using Electron Microscopy, Energy Dispersive X-ray Spectroscopy and Fourier-Transform Infrared Spectroscopy. Optimally functionalized frustules were evaluated for nickel removal from aqueous solutions. Incubations of 10 min, using 1 g/L of frustules, gave almost complete Ni removal with functionalized frustules compared to 3% removal by raw frustules. The proposed protocol represents a reproducible and efficient alternative for Ni removal from contaminated water.

BackgroundThe effect of fasting on immunity is unclear. Prolonged fasting is thought to increase the risk of infection due to dehydration. This study describes antibiotic prescribing patterns before, during, and after Ramadan in a primary care setting within the Pakistani and Bangladeshi populations in the UK, most of whom are Muslims, compared to those who do not observe Ramadan.MethodRetrospective controlled interrupted time series analysis of electronic health record data from primary care practices. The study consists of two groups: Pakistanis/Bangladeshis and white populations. For each group, we constructed a series of aggregated, daily prescription data from 2007 to 2017 for the 30 days preceding, during, and after Ramadan, respectively.FindingsControlling for the rate in the white population, there was no evidence of increased antibiotic prescription in the Pakistani/Bangladeshi population during Ramadan, as compared to before Ramadan (IRR: 0.994; 95% CI: 0.988-1.001, p = 0.082) or after Ramadan (IRR: 1.006; 95% CI: 0.999-1.013, p = 0.082).InterpretationIn this large, population-based study, we did not find any evidence to suggest that fasting was associated with an increased susceptibility to infection.

Mindfulness practice involves bringing one’s attention to the present moment and noticing events as they unfold with a non-judgmental attitude of acceptance. Although mindfulness has been shown to reduce stress and improve mental health, it can be challenging to learn mindfulness techniques. Recent years have seen an interest in using virtual reality (VR) to help people learn mindfulness by immersing users in virtual settings that support an external focus of attention and reduce everyday environmental distraction. However, the literature currently lacks an understanding of how VR should be designed to support mindfulness. In this paper we describe the iterative design and evaluation of Place, a VR app that supports mindfulness practice by situating the user in a virtual forest environment. We present findings from our design process in which prospective users trialled Place and provided feedback on the design in focus groups. Our findings draw attention to factors that influenced the user experience and acceptance of VR for mindfulness, and we describe how the design was altered to address these factors. We end by discussing key design choices that designers should consider when creating VR for mindfulness. Our contributions include insight into the importance of following an iterative design process when creating a VR mindfulness app, and a framework that can be used to inform the design of future VR apps for mindfulness practice.

Background: Little is known about factors associated with engagement with online interventions for psychosis. This review aimed to synthesise existing data from relevant literature to develop a working model of potential variables that may impact on engagement with online interventions for psychosis. Methods: Online databases were searched for studies relevant to predictors of engagement with online interventions for psychosis; predictors of Internet use amongst individuals with psychosis; and predictors of engagement with traditional psychosocial treatments for psychosis. Data were synthesised into a conceptual model highlighting factors relevant to engagement with online interventions for psychosis. Results: Sixty-one studies were identified. Factors relevant to engagement related directly to the impact of psychosis, response to psychosis, integration of technology into daily lives and intervention aspects. Conclusion: While several candidate predictors were identified, there is minimal research specifically investigated predictors of engagement with online interventions for psychosis. Further investigation examining both individual- and intervention-related factors is required to inform effective design and dissemination of online interventions for psychosis.

Abstract Background Internet-based interventions can make self-management and recovery-oriented information and tools more accessible for people experiencing severe mental illness, including psychosis. The aim of this scoping review was to identify and describe emerging joint uses of these Internet-based interventions by service users experiencing psychosis and mental health workers. It also investigated how using these Internet-based interventions influenced interactions between service users and workers and whether recovery-oriented working practices were elicited. Methods A scoping review method was used. Iterative review stages included identifying the review question, a comprehensive search including searching six electronic databases to locate relevant studies, selecting studies, charting the data, and collating and reporting the results. Rigour of the scoping review was enhanced by using an appraisal tool to evaluate the quality of included studies, and by using a published template for systematic description of interventions. Results Fifteen papers about eleven Internet-based interventions that focused on self-management and/or recovery were identified. Interventions were web-based, mobile-device based, or both. The eleven interventions were used by service users either with their usual mental health workers, or with mental health workers employed in a research project. Emerging evidence suggested that jointly using an Internet-based intervention could support a positive sense of working together. However, mismatched expectations and poor integration of Internet-based interventions into service systems could also negatively influence interactions, leading to mistrust. The interventions demonstrated potential to elicit recognised recovery-oriented practices, specifically understanding service users’ values and supporting their goal striving. Conclusions The use of Internet-based interventions focused on self-management and recovery in mental health services by service users and workers jointly demonstrates potential to support working together and recovery-oriented practice. Given that the quality of relationships is critical in recovery-oriented practice, greater focus on human support in Internet-based interventions is needed in future research and practice.

BackgroundDuring the COVID-19 pandemic, we saw telehealth rapidly become the primary way to receive mental health care. International research has validated many of the benefits and challenges of telehealth known beforehand for specific population groups. However, if telehealth is to assume prominence in future mental health service delivery, greater understanding of its capacity to be used to provide psychosocial support to people with complex and enduring mental health conditions is needed. ObjectiveWe focused on an Australian community-managed provider of psychosocial intervention and support. We aimed to understand service user and worker experiences of psychosocial support via telehealth throughout the COVID-19 pandemic. MethodsThis study was jointly developed and conducted by people with lived experience of mental ill health or distress, mental health service providers, and university-based researchers. Semistructured interviews were conducted between August and November 2020 and explored participant experiences of receiving or providing psychosocial support via telehealth, including telephone, text, and videoconferencing. Qualitative data were analyzed thematically; quantitative data were collated and analyzed using descriptive statistics. ResultsService users (n=20) and workers (n=8) completed individual interviews via telephone or videoconferencing platform. Service users received psychosocial support services by telephone (12/20, 60%), by videoconferencing (6/20, 30%), and by both telephone and videoconferencing (2/20, 10%). Of note, 55% (11/20) of service user participants stated a future preference for in-person psychosocial support services, 30% (6/20) preferred to receive a mixture of in-person and telehealth, and 15% (3/20) elected telehealth only. Two meta-themes emerged as integral to worker and service user experience of telehealth during the pandemic: (1) creating safety and comfort and (2) a whole new way of working. The first meta-theme comprises subthemes relating to a sense of safety and comfort while using telehealth; including trusting in the relationship and having and exercising choice and control. The second meta-theme contains subthemes reflecting key challenges and opportunities associated with the shift from in-person psychosocial support to telehealth. ConclusionsOverall, our findings highlighted that most service users experienced telehealth positively, but this was dependent on them continuing to get the support they needed in a way that was safe and comfortable. While access difficulties of a subgroup of service users should not be ignored, most service users and workers were able to adapt to telehealth by focusing on maintaining the relationship and using choice and flexibility to maintain service delivery. Although most research participants expressed a preference for a return to in-person psychosocial support or hybrid in-person and telehealth models, there was a general recognition that intentional use of telehealth could contribute to flexible and responsive service delivery. Challenges to telehealth provision of psychosocial support identified in this study are yet to be fully understood.

Backgrounde–Mental health resources are increasingly available for people who experience severe mental illness, including those who are users of community mental health services. However, the potential for service users (SUs) living with severe mental illness to use e–mental health resources together with their community mental health workers (MHWs) has received little attention. ObjectiveThis study aims to identify how jointly using an interactive website called Self-Management And Recovery Technology (SMART) in a community mental health context influenced therapeutic processes and interactions between SUs and MHWs from their perspective. MethodsWe conducted a qualitative study using a constructivist grounded theory methodology. Data were collected through individual semistructured interviews with 37 SUs and 15 MHWs who used the SMART website together for 2 to 6 months. Data analysis involved iterative phases of coding, constant comparison, memo writing, theoretical sampling, and consultation with stakeholders to support the study’s credibility. ResultsA substantive grounded theory, discovering ways to keep life on track, was developed, which portrays a shared discovery process arising from the SU-worker-SMART website interactions. The discovery process included choosing to use the website, revealing SUs’ experiences, exploring these experiences, and gaining new perspectives on how SUs did and could keep their lives on track. SUs and MHWs perceived that their three-way interactions were enjoyable, beneficial, and recovery focused when using the website together. They experienced the shared discovery process as relationship building—their interactions when using the website together were more engaging and equal. ConclusionsJointly using an e–mental health resource elicited recovery-oriented interactions and processes between SUs and MHWs that strengthened their therapeutic relationship in real-world community mental health services. Further work to develop and integrate this novel use of e–mental health in community mental health practice is warranted.

This paper describes the creation of a web-based digital resource designed for tablet computer use during peer work sessions to structure discussion about recovery in early psychosis. The resource consisted of a series of videos featuring young people who have used early psychosis services discussing how they navigated issues in their own recovery. A participatory process was used to create the resource. Researchers held a series of collaborative development workshops with early psychosis service users, peer workers, other mental health practitioners, and academics. These were used to derive a framework of recovery processes relevant to young people experiencing psychosis, which was considered as useful areas of discussion within a peer work relationship. A semi-structured interview guide based on this framework was then used in video-recorded interviews with young people in recovery from psychosis. Footage was edited into 14 videos and organized into six final themes: My Journey, Self-Care, Connections, My Identity, Life, and Mental Health. The combined expertise of young mental health service users, peer support workers, mental health practitioners, and digital mental health researchers throughout the development process enabled the creation of tailored digital resource for peer work in an early psychosis service.

Objectives To assess the acceptability and feasibility of using a theory-based electronic learning intervention designed to support appropriate antibiotic prescribing by nurse and pharmacist independent prescribers for patients presenting with common, acute, uncomplicated self-limiting respiratory tract infections (RTIs).Design Experimental with mixed methods; preintervention and postintervention online surveys and semistructured interviews.Setting Primary care settings across the UK.Participants 11 nurse and 4 pharmacist prescribers.Intervention A theory-based brief interactive animation electronic learning activity comprised a consultation scenario by a prescriber with an adult presenting with a common, acute, uncomplicated self-limiting RTI to support a ‘no antibiotic prescribing strategy’.Outcome measures Recruitment, response and attrition rates were assessed. The overall usefulness of the intervention was assessed by analysing prescribers’ self-reported confidence and knowledge in treating patients with RTIs before and after undertaking the intervention, and views on the relevance of the intervention to their work. Acceptability of the intervention was assessed in semistructured interviews. The feasibility of data collection methods was assessed by recording the number of study components completed by prescribers.Results 15 prescribers (maximum sample size) consented and completed all four stages of the study. Prescribers reported high to very high levels of confidence and knowledge preintervention and postintervention, with slight postintervention increases in communicating with patients and a slight reduction in building rapport. Qualitative findings supported quantitative findings; prescribers were reassured of their own practice which in turn increased their confidence and knowledge in consultations. The information in the intervention was not new to prescribers but was applicable and useful to consolidate learning and enable self-reflection. Completing the e-learning intervention was acceptable to prescribers.Conclusions It was feasible to conduct the study. The intervention was acceptable and useful to prescribers. Future work will add complex clinical content in the intervention before conducting a full trial.

In recent years, mindfulness-based interventions (MBI) have gained clinical relevance in the treatment of patients with schizophrenia spectrum disorders (SSDs). High symptom burden, long durations of hospitalization and high rehospitalization rates demonstrate the severity and cost-intensity of these disorders. MBIs have shown promising treatment outcomes in a small number of trials, primarily taking place in English-speaking countries. The current study aims to explore mechanisms and processes as well as adverse effects of MBIs on in-patients with SSDs in a German university hospital setting. A qualitative design based on inductive thematic analysis accompanied by quantitative assessments was chosen. A semi-structured interview guide was developed by psychiatrists and psychologists to assess patient experiences, perceptions, thoughts, and feelings during and after taking part in a MBI. Twenty-seven interviews were conducted between September 2017 and October 2018 with in-patients who are diagnosed with schizophrenia or schizoaffective disorder. Rater-based questionnaires, such as the Positive and Negative Syndrome Scale (PANSS), Montgomery Asberg Depression Rating Scale (MADRS), and Psychotic Symptom Rating Scales-Auditory Hallucination (PSYRATS-AH) were administered at baseline to collect clinical outcomes. Qualitative analysis revealed two domains: content and function. In the first domain related to content with the core elements “detachment and rumination”, “presence and getting lost”, “non-judgment and judgment”, and effects with “emotions”, “cognition”, and “symptom changes”. A second domain related to function was extracted, including the relevance of perception of context and transfer to everyday life. Overall, improvements concerning cognition, distress, and psychopathology were detected, while no adverse effects, such as increased psychotic symptoms, were revealed. As the first study of its kind, mechanisms, processes, and the safety of MBIs were explored and confirmed in a sample of German in-patients with SSDs. The results of this qualitative study are in line with recent findings on MBIs amongst patients with psychotic disorders from other countries. Results lay the ground for future research to focus on the systematic study of MBIs in large samples, its treatment processes, outcomes, and effectiveness for in-patients with SSDs.

This study explored participants' experiences of a novel intervention blending ecological momentary assessment and intervention (EMA/I) digital technologies with four face-to-face therapy sessions to improve coping in people who experience persisting auditory verbal hallucinations (hear voices). A smartphone app was used to deliver prompts to facilitate both self-monitoring and self-management of voices. Analysis of data recorded by the app was also used in-session to develop an idiographic formulation of antecedents of and responses to voice-hearing episodes. Semi-structured interviews were conducted with 12 participants who completed the blended therapy. A thematic approach was used to analyse the data, generating four main themes, with associated subthemes: (1) Therapy experience changed by digital technology; (2) Valuing face-to-face component; (3) Preference for different phases of the digital technology; (4) Not as bothered by voices. Key findings revealed that participants perceived EMA/I technology as helping capture their experience more accurately and communicate this more effectively to the therapist, which, in combination with coping prompts developed in-session, deepened the therapeutic relationship. These findings add to the emerging literature that shows blended therapy can play an important role in the treatment of people with psychosis, and suggest potential of EMA/I as a technology for other clinical populations. Keywords: Ecological momentary assessment, Experience sampling, Smartphone intervention, Personalized feedback, Auditory hallucinations, Schizophrenia

Common approaches to the psychological treatment of distressing voice hearing experiences, such as cognitive behavioural therapy, aim to promote more adaptive cognitive, emotional and behavioural responses to these experiences. Digital technologies such as smartphones show promise for supporting and enhancing these treatments by linking immediate therapeutic settings to the context of daily life. Two promising technologies include ecological momentary assessment and intervention (EMA/I), which may offer a means of advanced assessment and support in daily life, and inform the tailoring of interventions to suit individual needs. In this study, a highly novel intervention approach was developed involving four face-to-face sessions with a psychologist blended with EMA/I between sessions in order to improve coping with distressing voice hearing experiences. The authors describe the background and development of this approach along-side a single case illustration, which supported feasibility and acceptability. This study details how digital technologies such as EMA/I may be used in future as clinical tools to enhance standard psychological treatments and clinical care of people with persisting and distressing experiences. Keywords: Hearing voices, Auditory hallucinations, Digital technology, Smartphone, Blended therapy, Psychological treatment

Abstract Background The primary objective of this randomised controlled trial (RCT) is to establish the effectiveness of a novel online quality of life (QoL) intervention tailored for people with late stage (≥ 10 episodes) bipolar disorder (BD) compared with psychoeducation. Relative to early stage individuals, this late stage group may not benefit as much from existing psychosocial treatments. The intervention is a guided self-help, mindfulness based intervention (MBI) developed in consultation with consumers, designed specifically for web-based delivery, with email coaching support. Methods/design This international RCT will involve a comparison of the effectiveness and cost-effectiveness of two 5-week adjunctive online self-management interventions: Mindfulness for Bipolar 2.0 and an active control (Psychoeducation for Bipolar). A total of 300 participants will be recruited primarily via social media channels. Main inclusion criteria are: a diagnosis of BD (confirmed via a phone-administered structured diagnostic interview), no current mood episode, history of 10 or more mood episodes, no current psychotic features or active suicidality, under the care of a medical practitioner. Block randomisation will be used for allocation to the interventions, and participants will retain access to the program for 6 months. Evaluations will be conducted at pre- and post- treatment, and at 3- and 6- months follow-up. The primary outcome measure will be the Brief Quality of Life in Bipolar Disorder Scale (Brief QoL.BD), collected immediately post-intervention at 5 weeks (T1). Secondary measures include BD-related symptoms (mania, depression, anxiety, stress), time to first relapse, functioning, sleep quality, social rhythm stability and resource use. Measurements will be collected online and via telephone assessments at baseline (T0), 5 weeks (T1), three months (T2) and six months (T3). Candidate moderators (diagnosis, anxiety or substance comorbidities, demographics and current treatments) will be investigated as will putative therapeutic mechanisms including mindfulness, emotion regulation and self-compassion. A cost-effectiveness analysis will be conducted. Acceptability and any unwanted events (including adverse treatment reactions) will be documented and explored. Discussion This definitive trial will test the effectiveness and cost-effectiveness of a novel QoL focused, mindfulness based, online guided self-help intervention for late stage BD, and investigate its putative mechanisms of therapeutic action. Trial registration ClinicalTrials.gov: NCT03197974. Registered 23 June 2017.

Abstract Background Smartphone-based ecological momentary assessment and intervention (EMA/I) show promise for enhancing psychological treatments for psychosis. EMA has the potential to improve assessment and formulation of experiences which fluctuate day-to-day, and EMI may be used to prompt use of therapeutic strategies in daily life. The current study is an examination of these capabilities in the context of a brief, coping-focused intervention for distressing voice hearing experiences. Methods/design This is a rater-blinded, pilot randomised controlled trial comparing a four-session intervention in conjunction with use of smartphone EMA/I between sessions, versus treatment-as-usual. The recruitment target is 34 participants with persisting and distressing voice hearing experiences, recruited through a Voices Clinic based in Melbourne, Australia, and via wider advertising. Allocation will be made using minimisation procedure, balancing of the frequency of voices between groups. Assessments are completed at baseline and 8 weeks post-baseline. The primary outcomes of this trial will focus on feasibility and acceptability of the intervention and trial methodology, with secondary outcomes examining preliminary clinical effects related to overall voice severity, the emotional and functional impact of the voices, and emotional distress. Discussion This study offers a highly novel examination of specific smartphone capabilities and their integration with traditional psychological treatment for distressing voices. Such technology has potential to enhance psychological interventions and promote adaptation to distressing experiences. Trial registration Australian New Zealand Clinical Trial Registry, ACTRN12617000348358. Registered on 7 March 2017.

Background: Individuals with psychosis demonstrate positive attitudes towards utilising digital technology in mental health treatment. Although preliminary research suggests digital interventions are feasible and acceptable in this population, little is known about how to best promote engagement with these resources. Candidate predictors include therapist support, sources of motivation and recovery style. Understanding what factors predict engagement will aid more effective design and implementation of digital interventions to improve clinical benefits. Objective: This study aimed to investigate demographic, psychological, and treatment variables that predict overall and type of engagement with a psychosocial, online intervention for individuals with psychosis. Methods: Ninety-eight participants with a history of psychosis were given access to a web program containing modules on self-management and recovery, which they were asked to use flexibly at their own pace. Activity was automatically logged by the system. Baseline measures of demographics, recovery style and motivation were administered, and participants were randomised to receive either website access alone, or website access plus weekly, asynchronous emails from an online coach over 12 weeks. Log and baseline assessment data were used in negative binomial regressions to examine predictors of depth and breadth of use over the intervention period. A logistic regression was used to examine the impact of predictor variables on usage profiles (active or passive). Results: Depth and breadth of engagement were positively predicted by receiving email support, low levels of externally controlled motivations for website use, older age, and having a tertiary education. There was a significant interaction between level of controlled motivation and condition (+/−email) on breadth and depth of engagement: receiving asynchronous emails was associated with increased engagement for individuals with low, but not high, levels of externally controlled motivations. Receiving email support and more autonomous motivations for treatment predicted more active use of the website. Conclusions: Asynchronous email support can promote engagement with online interventions for individuals with psychosis, potentially enabling self-management of illness and improving clinical outcomes. However, those using online interventions due to external motivating factors, may have low levels of engagement with the intervention, irrespective of coaching provided. These findings may guide design and implementation of future online interventions in this population. Keywords: Digital technology, Digital mental health, Engagement, Intervention, Psychosis

BackgroundMental health patients can experience involuntary treatment as disempowering and stigmatising, and contact with recovered peers is cited as important for countering stigma and fostering agency and autonomy integral to recovery.AimsTo advance understanding of the interaction between involuntary treatment and contact with recovered peers, and explore hypothesised relationships to mechanisms of self-evaluation relevant to recovery.MethodEighty-nine adults diagnosed with serious mental illness completed items to assess involuntary treatment experience and the extent of prior contact with recovered peers, the Internalised Stigma of Mental Illness Scale, the Self-efficacy for Personal Recovery Scale, the Questionnaire about the Process of Recovery and relevant demographic and clinical scales.ResultsContact with recovered peers was found to moderate the effects of involuntary treatment on internalised stigma. Sequential conditional process models (i.e. moderated mediation) then demonstrated that conditional internalised stigma (i.e. moderated by contact with recovered peers) mediated the indirect effect of involuntary treatment on recovery-specific self-efficacy, which in turn influenced recovery. Compared with those with low contact with recovered peers, recovery scores were 3.54 points higher for those with high contact.ConclusionsAlthough study methods limit causative conclusions, findings are consistent with proposals that contact with recovered peers may be helpful for this patient group, and suggest this may be particularly relevant for those with involuntary treatment experience. Directions for future research, to further clarify measurement and conceptual tensions relating to the study of (dis)empowering experiences in mental health services, are discussed in detail.

Introduction Nurse and pharmacist independent prescribers manage patients with respiratory tract infections and are responsible for around 8% of all primary care antibiotic prescriptions. A range of factors influence the prescribing behaviour of these professionals, however, there are no interventions available specifically to support appropriate antibiotic prescribing behaviour by these groups. The aims of this paper are to describe (1) the development of an intervention to support appropriate antibiotic prescribing by nurse and pharmacist independent prescribers and (2) an acceptability and feasibility study designed to test its implementation with these prescribers.Method and analysis Development of intervention: a three-stage, eight-step method was used to identify relevant determinants of behaviour change and intervention components based on the Behaviour Change Wheel. The intervention is an online resource comprising underpinning knowledge and an interactive animation with a variety of open and closed questions to assess understanding. Acceptability and feasibility of intervention: nurse and pharmacist prescribers (n=12–15) will use the intervention. Evaluation includes semi-structured interviews to capture information about how the user reacts to the design, delivery and content of the intervention and influences on understanding and engagement, and a pre-post survey to assess participants’ perceptions of the impact of the intervention on knowledge, confidence and usefulness in terms of application to practice. Taking an initial inductive approach, data from interview transcripts will be coded and then analysed to derive themes. These themes will then be deductively mapped to the Capability, Opportunity, Motivation-Behaviour model. Descriptive statistics will be used to analyse the survey data, and trends identified.Ethics and dissemination Ethical approval for the study has been provided by the School of Healthcare Sciences Research Governance and Ethics Committee, Cardiff University. The findings will be disseminated via publication in peer-reviewed journals and through conference presentations.

[This corrects the article DOI: 10.1371/journal.pmed.1002488.].

Hypogean or enclosed monuments are important cultural heritage sites that can suffer biodegradation. Many of the stone walls of the prestigious Domus Aurea are overwhelmed by dense biofilms and so need intervention. Room 93 was chosen as a study site with the aim to test the efficacy of phyto-derivatives as new biocides. Laboratory studies were performed comparing the effects of liquorice leaf extract (Glycyrrhiza glabra L.), lavender essential oil (Lavandula angustifolia Mill.) and a combination of both. In situ studies were also performed to test the effect of liquorice. The results were compared with those of the commonly used synthetic biocide benzalkonium chloride. The effects on the biofilms were assessed by microscopy along with chlorophyll fluorescence analysis. The phototrophs in the biofilms were identified morphologically, while the heterotrophs were identified with culture analysis and 16S gene sequencing. Results showed that the mixed solution liquorice/lavender was the most effective in inhibiting the photosynthetic activities of biofilms in the laboratory tests; while, in situ, the effect of liquorice was particularly encouraging as an efficient and low-invasive biocide. The results demonstrate a high potential biocidal efficacy of the phyto-derivatives, but also highlight the need to develop an efficient application regime.

A number of health problems are associated with significant stigma, a social phenomenon in which individuals become the object of negative stereotypes. In addition to experiencing negative reactions from others, stigmatised individuals and groups can experience harmful consequences when they internalise these negative prevailing attitudes. The objective of this paper was to consider the potential to develop Internet-based health-related interventions explicitly targeting the effects of stigma on the individual. A review of the literature was conducted to synthesise current conceptualisations of stigma and self-stigma across a number of groups, and to identify current intervention developments. Self-stigma reduction strategies developed for in-person services include cognitive reframing, myth busting, contact with other members of the stigmatised group, and disclosure promotion. The development and provision of interventions targeting self-stigma within an online environment is in its infancy. Our review considers there to be particular potential of online interventions for this target, associated with the capacity of the Internet to promote having contact with peers within one’s stigmatised group, and for user interaction and empowerment. We conclude that self-stigma is a domain in which there is significant potential for innovation with health-related interventions, and provide a number of recommendations for online intervention development.

BackgroundGestational diabetes mellitus (GDM) is associated with developing type 2 diabetes, but very few studies have examined its effect on developing cardiovascular disease.Methods and findingsWe conducted a retrospective cohort study utilizing a large primary care database in the United Kingdom. From 1 February 1990 to 15 May 2016, 9,118 women diagnosed with GDM were identified and randomly matched with 37,281 control women by age and timing of pregnancy (up to 3 months). Adjusted incidence rate ratios (IRRs) with 95% confidence intervals (CIs) were calculated for cardiovascular risk factors and cardiovascular disease. Women with GDM were more likely to develop type 2 diabetes (IRR = 21.96; 95% CI 18.31-26.34) and hypertension (IRR = 1.85; 95% CI 1.59-2.16) after adjusting for age, Townsend (deprivation) quintile, body mass index, and smoking. For ischemic heart disease (IHD), the IRR was 2.78 (95% CI 1.37-5.66), and for cerebrovascular disease 0.95 (95% CI 0.51-1.77; p-value = 0.87), after adjusting for the above covariates and lipid-lowering medication and hypertension at baseline. Follow-up screening for type 2 diabetes and cardiovascular risk factors was poor. Limitations include potential selective documentation of severe GDM for women in primary care, higher surveillance for outcomes in women diagnosed with GDM than control women, and a short median follow-up postpartum period, with a small number of outcomes for IHD and cerebrovascular disease.ConclusionsWomen diagnosed with GDM were at very high risk of developing type 2 diabetes and had a significantly increased incidence of hypertension and IHD. Identifying this group of women in general practice and targeting cardiovascular risk factors could improve long-term outcomes.

The craniofacial skeleton is a complex and unique structure. The perturbation of its development can lead to craniofacial dysmorphology and associated morbidities. Our ability to prevent or mitigate craniofacial skeletal anomalies is at least partly dependent on our understanding of the unique physiological development of the craniofacial skeleton. Mouse models are critical tools for the study of craniofacial developmental abnormalities. However, there is a lack of detailed normative data of mouse craniofacial skeletal development in the literature. In this report, we employed high-resolution micro-computed tomography (μCT) in combination with morphometric measurements to analyze the postnatal craniofacial skeletal development from day 7 (P7) through day 390 (P390) of female C57BL/6NCrl mice, a widely used mouse strain. Our data demonstrates a unique craniofacial skeletal development pattern in female C57BL/6NCrl mice, and differentiates the early vs. late craniofacial growth patterns. Additionally, our data documents the complex and differential changes in bone parameters (thickness, bone volume, bone volume/tissue volume, bone mineral density, and tissue mineral density) of various craniofacial bones with different embryonic origins and ossification mechanisms during postnatal growth, which underscores the complexity of craniofacial bone development and provides a reference standard for future quantitative analysis of craniofacial bones.

In the burgeoning field of e-mental health interventions, avatars are increasingly being utilized to facilitate online communication between clients and therapists, and amongst peers. Avatars are digital self-representations which enable individuals to interact with each other in computer-based virtual environments. In this narrative review, we examine the psychotherapeutic applications of avatars that have been investigated and trialed to date. Five key applications were identified: (1) in the formation of online peer support communities; (2) replicating traditional modes of psychotherapy by using avatars as a vehicle to communicate within a wholly virtual environment; (3) using avatar technology to facilitate or augment face-to-face treatment; (4) as part of serious games, and (5) communication with an autonomous virtual therapist. Across these applications, avatars appeared to serve several functions conducive to treatment engagement: (1) facilitating the development of a virtual therapeutic alliance; (2) reducing communication barriers; (3) promoting treatment-seeking through anonymity; (4) promoting expression and exploration of client identity, and (5) enabling therapists to control and manipulate treatment stimuli. Further research into the feasibility and ethical implementation of avatar-based psychotherapies is required.

Robot software combines the challenges of general purpose and real-time software, requiring complex logic and bounded resource use. Physical safety, particularly for dynamic systems such as humanoid robots, depends on correct software. General purpose computation has converged on unix-like operating systems -- standardized as POSIX, the Portable Operating System Interface -- for devices from cellular phones to supercomputers. The modular, multi-process design typical of POSIX applications is effective for building complex and reliable software. Absent from POSIX, however, is an interproccess communication mechanism that prioritizes newer data as typically desired for control of physical systems. We address this need in the Ach communication library which provides suitable semantics and performance for real-time robot control. Although initially designed for humanoid robots, Ach has broader applicability to complex mechatronic devices -- humanoid and otherwise -- that require real-time coupling of sensors, control, planning, and actuation. The initial user space implementation of Ach was limited in the ability to receive data from multiple sources. We remove this limitation by implementing Ach as a Linux kernel module, enabling Ach's high-performance and latest-message-favored semantics within conventional POSIX communication pipelines. We discuss how these POSIX interfaces and design principles apply to robot software, and we present a case study using the Ach kernel module for communication on the Baxter robot.