Endometrial assessment procedures: an audit of current practice in Scotland

The objective was to determine, in relation to endometrial assessment procedures, the extent to which the current practice of gynaecologists in Scotland (as assessed both by questionnaire survey of clinicians and review of hospital records) accords with recommendations in recent evidence-based guidelines. All 132 consultant gynaecologists in Scotland were surveyed and 123 (93%) responded. In addition, the case records of 1199 consecutive women undergoing endometrial assessment procedures in 12 representative hospitals were reviewed. Over two thirds of consultants agreed that endometrial assessment procedures are seldom indicated in women aged under 40 years and over 80% agreed that when such procedures are indicated, outpatient endometrial biopsy represents the method of choice. However, the review of case records showed that 23% of the women who underwent endometrial assessment were aged under 40 years and only 44% of the procedures undertaken were out- patient endometrial biopsies. We conclude that some Scottish women may be undergoing endometrial assessment procedures unnecessarily and that, in some centres, traditional dilatation and curettage is being replaced by hysteroscopy under general anaesthetic in theatre although there is no evidence that this procedure provides more clinically useful information than out-patient endometrial biopsy.      

In Vivo Feedback Predicts Parent Behavior Change in the Attachment and Biobehavioral Catch-up Intervention

Understanding mechanisms and active ingredients of intervention is critical to training clinicians, particularly when interventions are transported from laboratories to communities. One promising active ingredient of parenting programs is clinicians’ in vivo feedback regarding parent–child interactions. The present study examined whether a form of in vivo feedback, in the moment commenting, predicted treatment retention and parent behavior change when the Attachment and Biobehavioral Catch-up (ABC) intervention was implemented in a community setting. Observational data were collected from 78 parent–child dyads (96% mothers; M age = 29 years; 81% minority; infants’ M age = 12 months; 90% minority) across 640 sessions conducted by 9 clinicians (100% female, M age = 39; 67% minority) in Hawaii. Parental behavior was assessed with a semistructured play task before and after intervention. Clinicians’ in-the-moment feedback to parents was assessed from intervention session videos. Clinicians’ frequency and quality of in-the-moment feedback predicted change in parental intrusiveness and sensitivity at posttreatment. Frequency of in-the-moment feedback also predicted likelihood of retention. Hierarchical linear modeling demonstrated strong support for these associations at the between-clinician level, and limited additional support at the within-clinician (i.e., between-case) level. Thus, a hypothesized active ingredient of treatment, in-the-moment feedback, predicted community-based ABC outcomes. The results complement lab-based evidence to suggest that in vivo feedback may be a mechanism of change in parenting interventions. Helping clinicians to provide frequent, high-quality in vivo feedback may improve parenting program outcomes in community settings.     

Treatment Precedes Positive Symptoms in North American Adolescent and Young Adult Clinical High Risk Cohort

Early intervention for psychotic disorders, a growing international priority, typically targets help-seeking populations with emerging psychotic (“positive”) symptoms. We assessed the nature of and degree to which treatment of individuals at high risk for psychosis preceded or followed the onset of positive symptoms. The North American Prodrome Longitudinal Study–2 collected psychosocial treatment histories for 745 (98%) of 764 high-risk participants (M age = 18.9, 57% male, 57.5% Caucasian, 19.1% Hispanic) recruited from 8 North American communities. Similar to prior findings, 82% of participants reported psychosocial treatment prior to baseline assessment, albeit with significant variability across sites (71%–96%). Participants first received treatment a median of 1.7 years prior to the onset of a recognizable psychosis-risk syndrome. Only one fourth sought initial treatment in the year following syndrome onset. Although mean sample age differed significantly by site, age at initial treatment (M = 14.1, SD = 5.0) did not. High rates of early treatment prior to syndrome onset make sense in light of known developmental precursors to psychotic disorders but are inconsistent with the low rates of treatment retrospectively reported by first-episode psychosis samples. Findings suggest that psychosis risk studies and clinics may need to more actively recruit and engage symptomatic but non-help-seeking individuals and that community clinicians be better trained to recognize both positive and nonspecific indicators of emerging psychosis. Improved treatments for nonspecific symptoms, as well as the characteristic attenuated positive symptoms, are needed.     

Parent Adherence in Two Behavioral Treatment Strategies for the Predominantly Inattentive Presentation of ADHD

We examined the effects of parent adherence on child outcomes in two treatment strategies for the Predominantly Inattentive Presentation of attention deficit/hyperactivity disorder (ADHD-I): behavioral parent training adapted for ADHD-I (Parent-Focused Therapy [PFT]) and a multicomponent intervention that combined PFT, a child life skills group, and a classroom intervention (Child Life and Attention Skills Program [CLAS]). In a 2-site randomized controlled trial, 199 children (7–11 years of age) were randomized to PFT (n = 74), CLAS (n = 74), or treatment as usual (n = 51). Parent adherence was rated separately by parents and clinicians. Child outcomes included ADHD-I symptoms and parent- and teacher- rated impairment social, organizational, and home impairment. Results from multiple regression analyses utilizing a composite of parent and clinician ratings showed that parent adherence predicted improvement in all 3 parent-rated child impairment outcomes and no teacher-rated outcomes in the PFT treatment group. Adherence ratings did not predict any parent- or teacher-rated outcomes in the CLAS treatment group and did not predict ADHD symptom change in either treatment condition. These findings suggest that when parents are solely responsible for teaching and reinforcing new child skills and behaviors (as in PFT), their adherence to the assigned intervention may be especially important for improvement at home. It may be less critical in multicomponent interventions, like CLAS, where the responsibility for teaching new child skills is shared among parents, teachers, and child group clinicians. Parent adherence does not appear to impact child improvement in the school setting.     

Delivering a lifestyle and weight loss intervention to individuals in real-world mental health settings: Lessons and opportunities

BACKGROUND: Most weight loss interventions for obesity-related risks exclude people with serious mental health conditions. PURPOSE: To adapt a successful lifestyle/weight loss intervention for this population, deliver it in an HMO and two public mental health clinics, and concurrently measure implementation factors. METHODS: Developmental and implementation-focused formative evaluations guided adaptations and identified barriers/facilitators to successful program deployment. RESULTS: Adaptations included content specific to the population's needs, consciousness-raising among clinicians and patients, additional case-management, and greater program flexibility. Barriers included instability in both settings from different sources. Facilitators included familiarity with groups, manual integrity, and appreciation of the program. It was delivered consistently across settings with maximum exposure and fairly good fidelity to the protocol (mean rating=1.7, 2.0=complete fidelity). CONCLUSIONS: This mixed-method implementation evaluation demonstrated that lifestyle/weight loss interventions in mental health settings are complex, but feasible, and valued by participants. Main program outcomes will be reported at the trial's conclusion.     

Development and Initial Psychometrics for a Therapist Competence Instrument for CBT for Youth Anxiety

Therapist competence is an important component of treatment integrity. This article reports on the development and initial psychometric assessment of the Cognitive-Behavioral Treatment for Anxiety in Youth Competence Scale (CBAY-C), an observational instrument designed to capture therapist limited-domain competence (i.e., competence in the delivery of core interventions and delivery methods found in a specific psychosocial treatment program) in the delivery of the core practice elements in individual cognitive-behavioral treatment (ICBT) for youth anxiety. Treatment sessions (N = 744) from 68 youth participants (M age = 10.60 years, SD = 2.03; 82.3% Caucasian; 52.9% male) of the same ICBT program for youth anxiety from (a) an efficacy study and (b) an effectiveness study were independently scored by 4 coders using observational instruments designed to assess therapist competence, treatment adherence, treatment differentiation, alliance, and client involvement. Interrater reliability—intraclass correlation coefficients (2,2)—for the item scores averaged 0.69 (SD = 0.11). The CBAY-C item, scale, and subscale (Skills, Exposure) scores showed evidence of validity via associations with observational instruments of treatment adherence to ICBT for youth anxiety, theory-based domains (cognitive-behavioral treatment, psychodynamic, family, client centered), alliance, and client involvement. Important to note, although the CBAY-C scale, subscale, and item scores did overlap with a corresponding observational treatment adherence instrument independently rated by coders, the degree of overlap was moderate, indicating that the CBAY-C assesses a distinct component of treatment integrity. Applications of the instrument and future research directions discussed include the measurement of treatment integrity and testing integrity-outcome relations.     

Have screening harms become newsworthy? News coverage of prostate and colorectal cancer screening since the 2008 USPSTF recommendation changes

In 2008, the US Preventive Services Task Force updated its recommendations to discourage screening for prostate cancer in men over 75 and for colorectal cancer in adults over 85. We aimed to determine whether newspapers portrayed these screenings differently after these recommendation changes. A quantitative content analysis included articles on prostate-specific antigen (PSA) testing or colonoscopy in US newspapers from 2005 to 2012. Outcomes included the number of benefits and harms mentioned and the gist expert and lay readers might get from articles. Benefits in PSA articles (n = 222) and harms and benefits in colonoscopy articles (n = 65) did not change over time. Mentions of PSA harms increased after 2008 (p < .01). Expected expert gist of PSA articles became more negative after 2008 (p < .01). Expected lay gist was positive and did not change. News coverage of PSA testing harms increased without a decrease in the discussion of benefits. Consumers, especially lay consumers, are receiving unbalanced information on cancer screening.     

Can't have one without the other: Mental health providers and community parents reducing barriers to services for families in urban poverty

University–community partnerships are widely recognized as critical to the success of community research and advocacy work but difficult to form and sustain. This article will describe a unique facet of that partnership, namely the collaboration between mental health clinicians and community consultants, a partnership that our data suggest was a cornerstone of our school‐based mental health service program called PALS, an ecological model designed to engage African American families living in urban poor communities in mental health services. The service model was designed to promote children's learning and positive behavior through supporting teachers and encouraging parental involvement in school. In PALS, parent representatives from the community and clinicians from the university worked together in school‐based teams to support children, families, and teachers. This article will discuss the evolution of our clinician–consultant partnership and several lessons that emerged regarding the incorporation of community members into the world of academia, research, and mental health service delivery. © 2007 Wiley Periodicals, Inc. J Comm Psychol 35: 435–446, 2007.     

Unpacking childhood experiences of abuse: Can clinicians identify their patients’ History of Abuse?

ABSTRACT

Emotional, physical and sexual abuse, have been consistently linked to mental health problems in adults. Previous research found that mental health providers rarely ask their patients about their childhood experiences of abuse. No study to date has examined the convergence of clinicians’ and patients’ reports of childhood abuse. The current study applied a multi-method, multi-informant approach to explore the concordance between patients’ reports of childhood experiences of abuse and clinicians’ identification of their patients’ history of abuse. Assessment of an independent interviewer was included. A convenience sample of clinicians (N = 80) and their patients (N = 170) in mental health clinics in care-as-usual settings participated in the study. To assess the history of abuse clinicians and patients completed the Clinical Data Form, patients additionally completed the Childhood Trauma Questionnaire. Independent interviewer completed the Familial Experiences Interview. Findings show that across all informants, exposure to emotional abuse was most prevalent, followed by physical abuse and least prevalent was sexual abuse. Additionally, clinicians reported lower prevalence of physical and sexual abuse among their patients as compared with the patient and independent interviewer’s reports. Moderate to strong correlations were observed between clinicians, patients and independent interviewer reports of emotional, physical and sexual childhood abuse. Moreover, the severity of the patient’s history of abuse was related to greater accuracy in clinicians’ reports. Clinicians are advised to collect explicit information regarding childhood abuse through interviews or valid measures. Clinicians should pay special attention when assessing patients with moderate severity of childhood abuse since they are frequently under-identified.     

Quality control in immunohistochemistry. Report of a workshop sponsored by the Biological Stain Commission

Although immunohistochemical methods are increasingly applied in diagnostic histopathology, there has been little standardization or quality control of immunoreagents; and published reports have not standardized Material and Methods for meaningful comparisons of results among clinicians. The Biological Stain Commission-sponsored workshop was convened to address the following issues: a manufacturers' testing program for probity of commercial antibodies, development of a manual for performance criteria and quality control assurance procedures, standardization of package inserts, standardization of information provided in the Materials and Methods sections of publications, establishment of a reagent and procedure clearing house, study of the effects of different fixation regimes on tissue antigens, and investigation of the environmental conditions needed for antigen-antibody interaction. The recommendations of the ad hoc committee and their implications for the future are discussed.     

Psychological treatments for persistent pain: an introduction

Psychological treatments for persistent pain have been demonstrated to be effective alternatives or adjuncts to more traditional methods for promoting optimal pain management. The primary goal of this issue is to provide the clinician with updated information on the state of the art of a variety of psychological treatments for persistent pain. Specifically emphasized are important issues that add to the complexity of effective pain management and practical recommendations for clinicians to use in enhancing the outcomes of these various treatment approaches. This introductory article provides a brief review of the empirical literature supporting the utility of psychological treatments for persistent pain, describes the content of this issue, and highlights several of the common themes highlighted by our panel of expert contributors.     

Therapists' adherence and competence and treatment discrimination in the NIDA Collaborative Cocaine Treatment Study

The National Institute on Drug Abuse Collaborative Cocaine Treatment Study was designed to assess the efficacy of four different psychosocial interventions (cognitive therapy, supportive-expressive dynamic therapy, and individual and group drug counseling) for cocaine dependence. This report addresses the treatment integrity and discriminability of the three individual treatments. Therapists' adherence and competence for all three individual treatments during early and late sessions were rated reliably by three sets of independent expert judges (one set of expert clinicians for each treatment condition). Results indicated that therapists and counselors made use of the therapeutic techniques described in their respective treatment manuals rather than those from different treatment manuals. Thus, treatments were easily discriminable by the independent judges.     

Identification of Distinct Latent Classes Related to Sleep,PTSD, Depression,and Anxiety in Individuals Diagnosed With Severe Alcohol Use Disorder

Objective/Background: Alcohol use disorders (AUDs) are often accompanied by comorbid physiologic and psychosocial conditions, including sleep disturbances. Sleep disturbances in these individuals may be associated with increased risk of relapse to drinking following detoxification and rehabilitation. Participants: The sample of inpatient treatment-seeking individuals with AUDs (N = 164) was 70.1% male and 47.6% African American with a mean age of 45.6 years (±9.5 years). Methods: Latent class analysis (LCA) was used to identify unmeasured class membership based on seven indicators: maximum Clinical Institute Withdrawal Assessment (CIWA) scores; sleep efficiency (actigraphy); sleep disturbances (Pittsburgh Sleep Quality Index-PSQI); anxiety or depression (Comprehensive Psychopathological Rating Scale [CPRS]); and current and lifetime posttraumatic stress disorder (PTSD). Results: The average number of drinking days in the 90 days preceding admission was 72.0 (±22.0 days), with an average of 13.16 drinks per day (±5.70 drinks). Nearly one quarter (24.4%) of respondents reported lifetime PTSD. Three latent classes were identified: Sleep Disturbance (SD); Sleep Disturbance, Anxiety and Depression (SD/AD); and Sleep Disturbance, Anxiety and Depression, and PTSD (SD/AD/PTSD). Members of the SD/AD/PTSD group were more likely to be female and had the highest withdrawal and sleep disturbance scores of all three groups. Conclusion: Findings support the use of LCA to identify subgroups of individuals with AUDs and accompanying sleep disturbances. Class identification may provide clinicians with insight into the integrative tailoring of interventions that meet the varied needs of individuals with AUDs, accompanying comorbidities, and sleep disturbances.     

Evidence Base Update of Psychosocial Treatments for Child and Adolescent Depression

Depression in youth is prevalent and disabling and tends to presage a chronic and recurrent course of illness and impairment in adulthood. Clinical trial research in youth depression has a 30-year history, and evidence-based treatment reviews appeared in 1998 and 2008. The current review of 42 randomized controlled trials (RCTs) updates these reviews to include RCTs published between 2008 and 2014 (N = 14) and reevaluates previously reviewed literature. Given the growing maturity of the field, this review utilized a stringent set of methodological criteria for trial inclusion, most notable for excluding trials based in subclinical samples of youth that had been included in previous reviews (N = 12) and including well-designed RCTs with null and negative findings (N = 8). Findings from the current review suggest that evidence for child treatments is notably weaker than for adolescent interventions, with no child treatments achieving well-established status and the evidentiary basis of treatments downgraded from previous reports. Cognitive behavioral therapy (CBT) for clinically depressed children appears to be possibly efficacious, with mixed findings across trials. For depressed adolescents, both CBT and interpersonal psychotherapy are well-established interventions, with evidence of efficacy in multiple trials by independent investigative teams. This positive conclusion is tempered by the small size of the interpersonal psychotherapy literature (N = 6) and concern that CBT effects may be attenuated in clinically complicated samples and when compared against active control conditions. Data on predictors, moderators, and mediators are examined and priorities for future research discussed.     

The quantity and quality of clinical practice guidelines for the management of depression in primary care in the UK.

BACKGROUND: Despite research evidence that guidelines can improve patient care, concerns remain over their cost-effectiveness. This is particularly so when there is a proliferation of guidelines for the same condition. Faced with differing recommendations, users will wish to make informed decisions on which guideline to follow. In creating a guideline appraisal instrument we have assessed guidelines developed in the United Kingdom (UK) for the management of a range of disorders including depression in primary care. AIM: To identify the number of UK clinical guidelines for the management of depression in primary care and to describe their quality and clinical content. METHOD: A survey was undertaken to identify all depression guidelines developed in the UK between January 1991 and January 1996. All guidelines produced by national organizations and a random sample of local guidelines were appraised using a validated instrument by six assessors: a national expert in the disease area, a general practitioner, a public health physician, a hospital consultant, a nurse specializing in the disease area, and a researcher on guideline methodology. The clinical content of each guideline was then assessed by one of the researchers (RB) according to a defined framework. RESULTS: Forty-five depression guidelines were identified. While there was a considerable range in the quality of the six national and three local guidelines appraised, at a group level their performance was similar to guidelines for other diseases. Clinical recommendations tended to reflect the joint consensus statement produced by the Royal College of General Practitioners and Royal College of Psychiatrists in 1992. The most obvious difference was in the style in which the guidelines were written and presented. CONCLUSION: A 'national template' was the starting place for most guidelines. Steps need to be taken to ensure that these templates are based on the best possible research evidence and professional opinion. Local clinicians should concentrate on effective dissemination and implementation strategies, rather than creating new guidelines.     

Outpatient parenteral antimicrobial therapy (OPAT) in the republic of Ireland: results of a national survey

Outpatient parenteral antimicrobial therapy (OPAT) services are not well developed in the Republic of Ireland. A national programme is being instituted to standardise care. This survey aims to assess the current use of outpatient intravenous antibiotics and to quantify the needs that physicians identify in the development of a national programme. General medical consultant physicians and clinical microbiology consultants were contacted through the Royal College of Physicians of Ireland (RCPI) from April to June 2012. Data were analysed using SPSS version 20. A total of 512 physicians were contacted, of which 55 (10.7 %) responded. The majority, 38/55 (69 %), practice general internal medicine in combination with a medical specialty, 2 (4 %) general internal medicine alone, 8 (15 %) clinical microbiology and 7 (13 %) a medical specialty alone. Of those practising a medical specialty, 12 (27 %) practice infectious diseases. Seventy-four percent reported having discharged patients with intravenous antibiotics; however, 47 % did not have a designated service available. Of those with no service, 100 % identified a need for these resources. Of those responsible for an OPAT service, 56 % had not audited their service. The most common indications were skin and soft tissue infections, osteomyelitis and respiratory tract infection. Flucloxacillin was the most commonly reported antibiotic. Eleven percent responded that they never monitor laboratory studies for patients discharged with intravenous antibiotics. While OPAT services in Ireland are not well developed, patients are being discharged with intravenous antibiotics. This survey underscores the need to develop the national programme to standardise care and ensure patients receive safe and efficient therapy.     

Reasons for declining computerized insulin protocol recommendations: application of a framework

Clinical decision support systems (CDS) can interpret detailed treatment protocols for ICU care providers. In open-loop systems, clinicians can decline protocol recommendations. We capture their reasons for declining as part of ongoing, iterative protocol validation and refinement processes. Even though our protocol was well-accepted by clinicians overall, noncompliance patterns revealed potential protocol improvement targets, and suggested ways to reduce barriers impeding software use. We applied Rita Kukafka and colleagues’ (2003) IT implementation framework to identify and categorize reasons documented by ICU nurses when declining recommendations from an insulin-titration protocol. Two methods were used to operationalize the framework: reasons for declining recommendations from actual software use, and a nurse questionnaire. Applying the framework exposed limitations of our data sources, and suggested ways to address those limitations; and facilitated our analyses and interpretations.